BPDFamily.com

Borderline Personality Disorder - Treatment and Cures

The conventional wisdom is that a behavior modification training is the best hope for people with Borderline Personality Disorder.  Some suggest that "talk therapy" is more affective.  Some will suggets the need for both.  There are also many opinions on the role of pharmaceuticals in dealing with BPD.

This workshop is to discuss the treatment available to people affected by Borderline Personality Disorder:

• What works?

• How does it work?

• What is the role of the family member?

• What is should the family members "not do"?

• What to expect?

Recent consensus seems to suggest that behavior modification training is most effective with people affected by Borderline Personality Disorder.  Cognitive Behavior Therapy (CBT), or one promising offshoot, Dialectical Behavioral Therapy (DBT) is the method most heavily evaluated in population studies.  There is also several others - Transferance (a preferred method at Columbia Presbyterian in NYC, for example) and the newer Schema, and Mentalization therapies that are being evaluated.

In the simplest sense, this is mostly about recognizing maladaptive behavior in yourself (the person affected by BPD), and using behavior tools to express it more constructively. Like a diet, it works only with someone who is motivated and committed.  Like a diet, many enter, some have short term gains but can't sustain the willpower.  And like a diet, setbacks in life can easily defeat the process.  Some patients start and restart.  Some start and then give up / dismiss it. 

For these reasons, it is important that the family and environment be both structured (helping avoid falling events) and encouraging (not defeating).  The family also need to be both patient and have boundaries with respect to digressions.

There is no "passive" cure.

The role of pharmaceuticals is mostly about:

• taking the "edge off" to help curb the extreme responses,  or to

• treat any underlying biological disease (e.g. thyroid disease, diabetes, etc) and secondary issues (e.g.,depression).

"taking the edge off" was explained to me as getting the patients "head above water" so that the work can be started... .rather than  a permanent solution or a stand alone cure.

I look forward to hearing the many diverse expereinces of the membership on this subject.

Skippy

Cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT), founded by Albert Ellis, Ph.D. is a combination of two therapy techniques: cognitive and behavioral. Cognitive therapy refers to an approach that focuses on a person's cognitions: their thoughts, assumptions, and beliefs. With this therapy approach a person learns to recognize and change faulty or maladaptive thought patterns. The focus is on restructuring the dysfunctional cognitions through a process of identifying, challenging, and reshaping them. Behavioral therapy focuses on changing a person's unhealthy and problematic behaviors, actions, and responses. The focus is not on "why" something happens, but changing the process to prevent, alter, or replace it with a healthier more effective behavior. Dialectical-behavioral therapy (DBT), and Schema-focused Therapy (SFT) are specialized types of CBT.


Dialectical-behavioral therapy

Developed by Marcia Linehan, Ph.D., of the Department of Psychology at the University of Washington, DBT directly targets suicidal and other dangerous, severe, or destabilizing behaviors. Standard DBT strives to increase behavioral capabilities, improve motivation for skillful behavior through management of issues and problems as they come up in day-to-day life and reduction of interfering emotions and cognitions, and structure the treatment environment so that it reinforces functional rather than dysfunctional behaviors. Therapy consists of weekly individual psychotherapy, group skills training, telephone consultation, and weekly meetings between therapist and a consultation team to enhance therapist motivation and skills and to provide therapy for the therapists. DBT skills for emotion regulation include:

   Identifying and labeling emotions

   

   Identifying obstacles to changing emotions

   

   Reducing vulnerability to emotion mind

   

   Increasing positive emotional events

   

   Increasing mindfulness to current emotions

   

   Taking opposite action

   

   Applying distress tolerance techniques

   


A recent report compares patients that DBT vs those that received treatment by community experts. The latter were therapists who were experienced in the treatment of BPD but used methods other than DBT to treat randomly assigned patients.

Subjects receiving DBT were half as likely to make a suicide attempt, required fewer hospitalizations for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined. They were also less likely to drop out of treatment and had fewer psychiatric hospitalizations and psychiatric emergency department visits, according to the report.

An abstract of the study, "Two-Year Randomized Controlled Trial and Follow-Up of Dialectical Behavior Therapy vs. Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder," is posted here.


Schema Therapy Builds on CBT

Schema therapy, the newest of the psychotherapies for BPD, appears to synthesize elements of several successful therapies. Paris has described it as "CBT with a psychodynamic component."

Schema therapy founder Jeffrey Young, Ph.D., who is on the faculty of the Department of Psychiatry at Columbia University College of Physicians and Surgeons, was one of the first students of Aaron Beck, M.D., the founder of cognitive therapy.

"I found that cognitive therapy was extremely effective with many Axis I disorders, as research has since substantiated, but was much less effective by itself with Axis II personality disorders," he told Psychiatric News. "I began to look for ways to expand cognitive-behavior therapy to work with Axis II issues by integrating elements drawn from other approaches as well as CBT, including psychodynamic therapies such as object relations, emotion-focused/gestalt therapies, and attachment theory."

Young described schema therapy as an active, structured therapy for assessing and changing deep-rooted psychological problems by looking at repetitive life patterns and core life themes, called "schemas." Schema therapists use an inventory to assess the schemas that cause persistent problems in a patient's life.

"Once we have determined what schemas a patient has, we use a range of techniques for changing these schemas," Young said. "These include cognitive restructuring, limited re-parenting, changing schemas as they arise in the therapy relationship, intensive imagery work to access and change the source of schemas, and creating dialogues between the `schema,' or dysfunctional, side of patients and the healthy side."

He added that systematic behavioral techniques are also employed to change dysfunctional coping styles, especially maladaptive behaviors in intimate relationships. More information about schema therapy is posted here.

In a randomized trial of schema therapy versus transference-focused therapy published in the Archives in June 2006, statistically and clinically significant improvements were found for both treatments on all measures after one, two, and three-year treatment periods. Data on 44 schema therapy patients and 42 transference-focused therapy patients were available.

Main outcome measures included scores on the Borderline Personality Disorder Severity Index, quality of life, and general psychopat hologic dysf unction. Patient assessments were made before randomization and then every three months for three years.

Significantly more schema therapy patients fully recovered (46 percent versus 26 percent) or showed reliable clinical improvement (66 percent versus 33 percent) on the Borderline Personality Disorder Severity Index than patients receiving transference-focused therapy. They also improved more in general psychopathologic dysfunction and showed greater increases in quality of life.

Statistical analysis also revealed a higher dropout risk among transference-focused therapy (52 percent) patients than among patients receiving schema therapy (29 percent), according to the study report.

The report, "Outpatient Psychotherapy for Borderline Personality Disorder: Randomized Trial of Schema-Focused Therapy vs. Transference-Focused Psychotherapy," is posted here.

"This is the first controlled study demonstrating that a treatment is capable of reducing all of the BPD manifestations as defined by DSM-IV, reduces associated personality features and general psychopathology, and increases quality of life," study co-author Arnoud Arntz, Ph.D., told Psychiatric News.

He is with the Department of Medical, Clinical, and Experimental Psychology at the University of Maastricht, in the Netherlands.

The authors also stated that, in a separate analysis, schema therapy was found to be highly cost-effective for society, despite the length and intensity of the treatment.

Young, who was not involved in the study, said it is the first to demonstrate "deep personality change" in a high percentage of patients long considered untreatable.

"Up until now, existing therapies for BPD have proven to lead to only partial recovery or have only been able to reduce self-harming behaviors," he said. "This should be of great interest to psychiatrists because patients with BPD are usually considered the most difficult, frustrating, and risky patients within most therapists' practices.

"The second important implication for psychiatrists is that the use of a neutral stance toward the BPD patient, which is advocated in most psychody namic approaches to BPD, is clearly much less effective than the more engaged, warm, and nurturing stance of schema therapy," Young said. "This was demonstrated by the dramatic differences in dropout rates between the two treatments."


Mentalization Therapy

It has been proposed that people with BPD have hyperactive attachment systems as a result of their history or biological predisposition, which may account for their reduced capacity to mentalize. They would be particularly vulnerable to side-effects of psychotherapeutic treatments that activate this attachment system. Because the approach is psychodynamic, therapy tends to be less directive than cognitive-behavioral approaches, such as dialectical behavior therapy (DBT), another common treatment approach for borderline personality disorder. More information is posted here.

Mentalization is the capacity to understand both behavior and feelings and how they’re associated with specific mental states, not just in the client, but in others as well. It is theorized that people with Borderline Personality Disorder (BPD) have a decreased capacity for mentalization. Mentalization-based therapy, pioneered by Andrew Bateman, M.A., and Peter Fonagy, Ph.D., seeks to facilitate the capacity for "mentalization"—the ability to perceive the mind of others as distinct from one's own and hence to reconsider and reassess one's own perceptions of reality. Mentalization is a component in most traditional types of psychotherapy, but it is not usually the primary focus of such therapy approaches.

Transference-focused Psychotherapy

Transference-focused Psychotherapy (TFP), founded by Otto Kernberg, M.D., is a psychodynamic treatment designed especially for patients with borderline personality disorder (BPD). Transference-focused psychotherapy among others, is an adaptation of psychoanalysis that aims to correct distortions in the patient's perception of significant others and of the therapist.

TFP, which dates back many years, places special emphasis on the assessment and on the treatment contract between the client and the therapist. The setting up of the contract and frame has a behavioral quality in that parameters are established to deal with the likely threats both to the treatment and to the patient's well-being that may occur in the course of the treatment. The patient is engaged as a collaborator in setting up these conditions.

After the behavioral symptoms of borderline pathology are contained through structure and limit setting, the psychological structure that is believed to be the core of borderline personality is analyzed as it unfolds in the relation with the therapist as perceived by the patient [transference]. More information is posted here

One thing you might want to keep in mind is that all the research on treatments showing improvements have been done on low functioning, inward acting BPs who primary issues are staying alive and not hurting themselves--especially DBT. They all require a major commitent on the part of the patient.We don't really have any research on any other types of patients. Randi Kreger

This makes me wonder ... .especially because high functioning BPDs often are not even diagnosed as BPD but as something else, for reasons of insurance, increased compliance from the patient, stigma avoidance, etc.

Sounds like it would be quite difficult to do effective studies of treatments for high-functioning BPDs.

Linehan's DBT research has been replicated and expanded upon since the first publication... .so though it might not be as plentiful as the original validating studies, I'd say that just about every group and sub-type of borderline individual has been studied under this type of treatment.  Within the last few years, it's even been modified for children and adolescents.

I think the biggest issue with treatment of the highest functioning borderlines would be the fact that they aren't seeking treatment.  If they are truly high functioning, they won't be forced into treatment by circumstances that typically lead people to seek help with their symptoms.  They play "well" with others... .  get it, double meaning... ."well" as in "healthy" and "well" as in "get along gang happy." 

I would think it would be a reasonable leap to generalize results of the components of the treatments to the high funct BPD's.  All treatment modalities are interconnected and either build upon previous theory or have theories shooting forth from it.  While the beginning research for methods like DBT did focus on individuals with overt borderline behaviors and past history of serious symptoms, the theories and related treatments have been researched on multiple populations of individuals with varying symptomology.

Some of the aspects, like mindfulness in DBT, have been around for millenia.  More time tested than empiracally so... .but definitely the exposure to multiple levels of pathology and functioning exist and the method still persists as reliable... .if only through folklore and tradition until disproven by data. 

My personal belief is that the lines are so blurry between diagnoses and criteria that research on populations/diagnostic categories isn't as effective as research on symptoms/behaviors.  Of course, there are hundreds of scientists with decades of experience who would slap me in the face for taking such a stand.  I'm just a fraction fan and always try to find that least common denominator and start from there... .

 I just saw an article in a local paper about Schema therapy being 60% effective in people with BPD within 6 months. Sounds too good to be true. Can someone explain the difference between DBT and Schema and is one more effective that the other?

thanks,

Morgause

You know, as much as this is interesting, you'd be hard pressed to find schema therapy anywhere local. It's only being offered in NYT, as far as I know.If I had to say the difference in a nutshell, I would say that schema has the focus on skills like DBT, but with much more of an emphasis on psychotherapy to the point where the therapist helps nurture the patient. I think that makes a lot of sense. 

Here is a link that can be used to search for therapists by therapy type:

www.goodtherapy.org/find (http://www.goodtherapy.org/advanced-search.html)

It's not a huge database.  For Philadelphia, it lists 23 therapists (all types) of which 3 are DBT therapists listed, 2 are Schema therapists.

In Chicago,  4 DBT therapists listed, 1 Schema. In San Francisco, 10 DBT therapists listed, 2 Schema.

Thanks for the answer. I live in Netherlands where for some reason there seems to be large number of people with BPD despite the small population. Therapy is covered under most insurance policies, and they seem to favor Schema therapy for BPD over DBT here. Is it true that Schema therapy is more effective and recovery is faster? I was a bit skeptical of the 6 month recovery prognosis myself... (in a study done by the Vrije Universiteit Medisch Centrum) But it was written in a top newspaper (NRC)

If schema therapy is so effective, why aren't more BPD treated by it instead of DBT?

Right now there is a lot of competition between various researchers as to see whose therapy is more effective, nanny nanny na na na, "MY therapy is better than YOUR therapy, so there!" I am reading through the lined about this, but that is generally how things go. There are other therapies such as transference focused therapy (www.borderline-personality.suite101.com/article.cfm/transferencefocused_psychotherapy) and mentalization (www.BPD.about.com/od/treatments/a/mentalize.htm) and I think it's fair to say that everyone wants a piece of the pie. Studies showing effectiveness are necessary to getting reinbursed, which is why these studies are so critical. My personal belief was borne out by this study: Highly Structured Therapies Prove Their Efficacy in BPD                         Any structured, symptom-focused treatment for borderline personality disorder is likely to be better than the unstructured care patients typically get in the community. www.pn.psychiatryonline.org/content/45/2/22.1.fullI think it's kind of obvious that therapists who are specially treated and focus in on BPD and take an interest in this population and their special needs are going to be better. But DBT takes the cake right now simply because it's been around the longest--Marsha Linehan published her seminal text and workbook in 1993 and it has a big head start at providing training. Take a look at Behavioraltech.com. Her courses and products are very expensive. It takes a great deal of money to train clinicians in new techniques and put new programs in clinical settings. I don't remember which therapy in the Netherlands is available. But whatever it is, it's going to better than treatment as usual IF your BP is a good match for what they offer. Remember they're all focused on the lower-functioning conventional BP.

Point well taken, Randi.

Here is a paper arguing the merits of Mentalization therapy... .

The British Journal of Psychiatry (2006) 188: 1-3. doi: 10.1192/bjp.bp.105.012088 (http://www.bjp.rcpsych.org/cgi/content/full/bjprcpsych;188/1/1)

A promising evidence base is also available for psychodynamically oriented interventions. A randomised controlled trial of treatment of borderline personality disorder in a psychotherapeutically orientated day hospital offering modified individual and group psychoanalytical psychotherapy (Bateman & Fonagy, 1999, 2001) has shown significant and enduring changes in mood states and interpersonal functioning associated with an 18 month programme (effect size= -2.36, 95% CI -3.18 to -1.54). The benefits, relative to usual treatment, were considerable and observed to increase during the follow-up period of 18 months, rather than staying level as with dialectical behaviour therapy.

The Cornell Medical College Group recently reported the only head-to-head comparison of psychodynamic and dialectical-behavioural therapy (Clarkin et al, 2004). They found significant improvements in impulsivity-related symptoms, as well as mood and interpersonal functioning measures. The trial contrasted transference-focused psychotherapy, dialectical behaviour therapy and supportive psychotherapy. There was significant and equal benefit from all the interventions, although early drop-out rates were higher for dialectical behaviour therapy than for the other treatments.

I would like to see studies on DBT being effective with high functioning "invisible" BPDs as well. Seems that DBT is focused more on the extremely abhorrent BPD behaviors like suicide and self mutilation.

Keep in mind that Marsha Linehan was working with what she called "The worst suicidal patients" when she was formulating DBT. She even admits she hadn't even heard of BPD until one of her colleagues mentioned that it seemed she was treating almost all borderlines. She then began to read up on borderline personality disorder and came to the conclusion that she was in fact treating borderline personality disorder.

Nevertheless, I think DBT has been extremely effective in determining what exactly it is that makes borderlines so difficult to treat and why they need to be treated completely different from other patients. Linehan puts it best when she posed the question of how do you treat a person that needs to change that is "terribly sensitive to being told that they need to change."

I think that any sort of therapy that understands this, and is more subtle with the "you are the patient, I am the therapist" type therapeutic relationships, can be very effective. Borderlines need to somehow learn to grow emotionally, this takes a nonthreatening environment which is hard to establish but it can be done. The problem with high functioning borderlines, is that they don't feel they need to change. The rest of their life is just "peachy" except their relationship partners. So its a lot easier to change partners than face the void of emptiness. Low functioning borderlines, who are much more prone to self-mutilation and suicide, have highly dysfunctional lives, far beyond just shattered relationships. So its easier for them to "radically accept" that they need to change. This gives the therapist a lot more leverage than with a high functioning borderline.

Anyone have a success story of a high functioning borderline being treated with DBT?

I am a therapist who works quite a bit with DBT, Schema therapy, and mentalization, often with folks who could be described as borderline.  These are some of my impressions off the top of my head.  Sorry to not have more detail, www.pubmed.gov is a good source for current research (coupled with a friendly librarian!).

Schema therapy is an integrated therapy, that is, it integrates from other, previously existing therapies, mostly CBT, Gestalt, psychoanalytic (particularly object relations), and attachment theory.  I haven't seen research looking at six months of treatment for BPD.  I would love to see it if someone can find a reference.  Most research I've seen has looked more at 2-3 years of usually twice a week outpatient Schema therapy.  Outcomes have been among the best for BPD research.  One notable thing to my mind, drop out has been particularly low.

DBT seems to me to focus very well on skills to manage behaviors, emotions, and relationships.  I usually integrate a lot of DBT into the Schema work I do with people.  A lot of Schema therapists seem to take this approach.  I think it may be a next step in the evolution of Schema therapy.  DBT has good outcomes in research, but may not be particularly strong in helping with some of the mood problems with BPD and drop out is higher than Schema.

Mentalization Based Therapy also has very good outcomes and lower drop out than DBT.  It seems to focus a lot on building psychological mindedness in patients with BPD -- reflecting on one's own mind, emotions, motivations, etc. and those of others.  Mentalization has been used as a stand alone treatment and has been viewed as an active ingredient of other therapies.  I use it as the later.  I think Schema therapy is an excellent mentalization therapy -- it has depth and a very accessible, understandable terminology that I think helps increase patients' (and therapists'!) mentalization very well.  Peter Fonagy and his gorup are the leaders here.  (DBT, particularly with its focus on mindfulness, can also be seen as increasing mentalization.)

The Schema Therapy Institute in NYC is probably the best place for referrals for Schema therapists.  (By the way, this post is not a personal plug, I am not certified by them so they won't be giving my name.  This is just a topic close to my heart, and, it seems to others here so I wanted to share.) www.schematherapy.com

The Netherlands seems to have embraced Schema therapy as the national insurance's therapy of choice for BPD (or that's what I can gather from my limited perspective here in the US).  There is a lot of excellent Schema research and clinical growth happening there. 

 DBT truly worked a miracle for my husband. He went for 3 years... often, a year isnt long enough... .and he now is considered recovered from BPD. No rages, so suicide stuff, no inappropriate behaviors... for over 2 years now.  |iiii

   Steph

My BPDbf went for 2 years and it helped him loads. I think the recommended time to be going to DBT is between 2 and 5 years! He still has issues but it helped him a lot and he's not half as bad as he used to be.

All the best  :)

my partner has been in dbt for abt 2.5 years... i think it does help... but its probably in the last year or so that theres the biggest difference

My H attended DBT for 18 mos. and although he knew he needed to continue, stopped. It helped him tremendously. He still has BPD and issues that go along with it, but he is nowhere near what he used to be.

He is in T and MC, currently as he knows he needs help, but will/can not make time for DBT.

Lem

My partner has done 9 years of psychotherapy, a year of 5-day a week DBT course, a year of PTSD group, and is currently doing psychotherapy and an anger management group. She's also been on a variety of meds.

The DBT was amazing for her. She really took it seriously, and her behavior has changed so much it's very impressive. She's still not perfect, but she's functioning so much better in every area of her life.

My wife has gone through DBT for 6 months before she was kicked out of the program for missing too many therapy appointments.  While she hasn't gone through the full course of at least a year, I've found that DBT has proven itself useful.  She's much more under control than she was.

You will find lots of disagreements from proponents of each type of therapy. It's a bit like politics--wait, it IS politics.WHile studies can make generalities, each person is different, and what is right for one person may not be right for each other. In addition, even with standard BPD therapy, not all therapists are the same. Also, believe it or not, some people say they do DBT when they really don't have a whole program in place and technically they're not providing real DBT.Randi KregerThe Essential Family Guide to Borderline Personality Disorder

I see alot of reference to DBT as the preferred method to treatment of BPD.  And I have researched it a little, it seems like it is more intensive (phone calls, groups, extra visits) and involves some tools like cards.  But how does a DBT session differ from a standard CBT session? 

Hey MagentaOrchid

This is weird - before I saw your message I stumbled upon this kind of by accident at work when I was looking up something else. But this is the best explanation I've seen - it explicitly addresses how DBT differs from CBT.

www.mind.org.uk/help/medical_and_alternative_care/dialectical_behaviour_therapy

Bear in mind that it tends to stereotype BPDs as young women who self-harm, I don't know if that is just a UK thing but it really annoys me.

Hope the factsheet helps

Annie xoxo

DBT is under the umbrella of CBT. CBT therapy is talking to your therapist who tried to explain that your thoughts affect your feelings, which affect your behavior. That is CBT in essence.DPT is an entire program based on that theory as well as many other theories such a the dialectic, mindfullness, radical acceptance, and others. There is once a week meeting with a therapist, but the skills classes are really central to the therapy. The diary cards are one way to track the thoughts, feelings, and behaviors.

a true dbt program will consist of individual therapy weekly + group skills therapy weekly accompanied by access via telephone to their therapist for support in the event of severe dysregulation.  therapists who practice dbt and work with pwBPD also need to have support for themselves to prevent "burn out".

due to our geographic location we were unable to get dbt for our teen daughter.  once i found a t who had experience w/BPD and BPD adolescents (he is also on staff at the state hospital) i asked him to learn about dbt and bought him the books he would need.  i also paid for 1/2 of the online training offered by behavioraltechllc. (you can learn all about dbt on that site).

my daughter refused to use any of the skills taught in the dbt program and we did not have access to group skills for teens.  since she refused to work at it... .we made the decision to send her to a residential treatment facility.  at this facility her individual therapist has been successful in teaching her the coping skills taught in the dbt program.  she has group therapy (PPC) not dbt which has helped her immensely as well.  she also does equine therapy... .that has also been very very helpful. 

the bottom line... .dbt is great if you can get it! 

lbjnltx

Thank you for answering my question. My BPD GF gets everything but the group which is available to her but she stopped going. How effective is dpt without the group componant? To me it seems that once she stopped going to group things got much worse in terms of dysregulation frequency and intensity.

in my opinion group therapy is just as important (especially for teens as their peer group has the most influence over them) as the individual therapy.

if your gf won't attend group there is an alternative.  this online support group for pwBPD teaches and reinforces dbt skills. www.dbtselfhelp.com  perhaps she would participate there... .it is better than nothing.

non's are also welcome on that site.

lbjnltx

Thank You! I greatly appreciate your help. We are currently in no contact and things have not been and are not good between us. If I ever do decide to talk to her about this I would recommend that site to her. It is and has always been difficult for me as she forbids me from being on any of these sites and does not understand how important they are to us. Every recommendation I have made every book I have purchased have all been ignorred as though she doesn't need to be bothered with any of it.

We moved her bed out a few months ago to reattach the head board and the box of books I bought for her was under the bed never opened even though I gave them to her a year ago. I think it scares her to read about what she may do to me and if she reads that it is wrong then she can no longer pretend that I should just suck it up and deal with it. That's just my opinion.

Thanks Again!

BPD... .the disorder that exists to be denied.

all the disordered behaviors of a BPD are survival techniques.

lbjnltx

<<My question is: What should a "whole program" include?The web site www.NEABPD.org I THINK has a list of questions to ask any DBT program. One other thing a real program has is a weekly meeting where the therapists get together to share info on patients and support each other. That's a critical component. Also look to the site www.behavioraltech.com. There is a list of DBT therapists.

Does anyone know if there are comprehensive studies, statistics somewhere on the success of BDP recovery of those that are in treatment? Broken down by age, gender, years of therapy, kind of therapy, etc?

There are numerous studies out there.  Here a few;

The Longitudinal Course of Borderline Psychopathology: 6-Year Prospective Follow-Up of the Phenomenology of Borderline Personality Disorder

Mary C. Zanarini, Ed.D., Frances R. Frankenburg, M.D., John Hennen, Ph.D., and Kenneth R. Silk, M.D.

Of the subjects with borderline personality disorder, 34.5% met the criteria for remission at 2 years, 49.4% at 4 years, 68.6% at 6 years, and 73.5% over the entire follow-up. Only 5.9% of those with remissions experienced recurrences.


Progress in the treatment of borderline personality disorder

PETER FONAGY, PhD, FBA

University College London and The Anna Freud Centre, London

After 6 years, 75% of patients diagnosed with borderline personality disorder severe enough to require hospitalization, achieve remission by standardized diagnostic criteria.  Recurrences are rare, perhaps no more than 10% over 6 years.

Effectiveness of Psychotherapy for Personality Disorders

J. Christopher Perry, M.P.H., M.D., Elisabeth Banon, M.D., and Floriana Ianni, M.D.

All studies reported improvement in personality disorders with psychotherapy. The mean pre-post effect sizes within treatments were large: 1.11 for self-report measures and 1.29 for observational measures. Among the three randomized, controlled treatment trials, active psychotherapy was more effective than no treatment according to self-report measures. In four studies, a mean of 52% of patients remaining in therapy recovered—defined as no longer meeting the full criteria for personality disorder—after a mean of 1.3 years of treatment. A heuristic model based on these findings estimated that 25.8% of personality disorder patients recovered per year of therapy, a rate sevenfold larger than that in a published model of the natural history of borderline personality disorder (3.7% recovered per year, with recovery of 50% of patients requiring 10.5 years of naturalistic follow-up).

Skip, that was very helpful, thank you. I found all three, downloaded, and skimmed through them (will read in detail later on). From the first glance, they don't appear to include the breakdown by age, gender, etc. Are you aware of studies that reveal "demographics" on those recovered, as well as those not?

For example: Is someone who is 50 less likely to recover than someone who is 30? Does the substance abuse history matter? Does gender matter? What is the difference between success rates for DBT vs CBT?

But my question is... .what percent of pwBPD get this help? My money is on not many. What's the drop out rate even if they do start therapy?

Now that is the real question. Look at how many of us have undiagnosed BPDs. For one to not be so narcissistic or stuck in their own ways enough to even admit to going to therapy would seem rare to me. It would appear those would be the higher functioning BPDs or those that barely meet the criteria with less co-morbidity.

Aren't there really only two important points. 

(1) If our ex-partners got into treatment and engaged that there is hope but that didn't happen on our watch (for whatever reason). 

(2) 74% of us are depressed and if got we got into treatment and engaged that the recover rate and treatment time is significantly shorter, but many of us are not seeking treatment - for whatever reason - can't afford it - don't believe in the medications - don't have time - are not motivated.

It is true - the best therapies on earth ate useless unless the people that need them are willing to engage them.

It is (1) that is giving me the most grief - my ex did get diagnosed on my watch - as a result of depression and high emotional stress experienced due to US. The diagnosis happened in December. But... .3 years of mounting stresses, things getting even more worse for him, my not being willing to live with more lies and setting more boundaries didn't exactly give us the perfect time to benefit from years of therapy. We broke up by February. I cannot help but wonder... .what if I waited... .what if I had stuck somehow... .

This is one of the top reasons members of the leaving/detaching board gravitate more toward a pessimistic view of BPD and people with BPD than say partners working on it or parents... .because it is hard to deal with the "what if".

Recovery often requires someone in the life of the pwBPD that they trust as unconditionally loving them - not a pus - but someone that has that trust.

When our relationship cratered, most likely a lot of damage was done - it would not be likely we could fill this role - or be seen as the person of trust by the pwBPD.

If I had known what I know now before the relationship started, I could have handled it much better.  But, if I had know it was BPD, I probably would have exited.

I only say this to point out that a lot of things have to align to make it work.  We have members that have done that. 

I know that I have skills now for the next relationship - and they are good skills -  and that is where I am focused.   :)

You're past the point of this being relevant, right?  How to get a BPD partner into treatment is really a topic for the Staying board.

Are you sure about this? Do they ever really trust someone unconditionally?

One of the most painful (and difficult) facts to accept - that "our" response typically enables the pwBPD to stay sick and not seek treatment.

~ Our walking on eggshells gives them a false view of life.

~ Our weak boundaries gives them a false belief that they have control and power over others.

~ Our inability to take care of ourselves (our sacrifices for love) feeds the spoiled inner child in them.

~ Our tendency to focus on them and their needs ensures that our own issues stay buried.

~ Our perpetual forgiveness after they hurt us sends the message that it is OK for them to hurt us.

~ Since their unhealthy ways of coping (emotional blackmail, raging, playing the victim/waif, etc) work, they continue to use them.


Everything in life has a action - reaction - action - reaction cycle to it. Nothing happens in a vacuum. When we change our reactions to their dysfunctional ways of behaving we are breaking our end of the cycle, thus forcing them to respond in different ways.  

The perception that age makes things worse is because like a spoiled child without rules or boundaries, it's easy to lose track of what's appropriate and what's not.

We teach people how to treat us by the behavior we accept from them

Well written;

Yes this was 100% my side of the equation, I had no idea what sort of cycle I was working with until after our last split (finding this resource)


Sometimes it appeared  we were making communication progress after I was setting a boundary, we made a plan to avoid the conflict we both agreed on but when she would steer back into that behavior and not respect our plan of action my response would be based upon frustration (doesn't this girl respect me, we had an understanding!),  we'd have a fight (by email) then I would suggest a break, then  she would use a waif/victim/sexual promises tactics to lure me back in and my biggest mistake was to think the coast was clear then and not stick to enforcing the boundary and plan, I was expecting her to be a full adult partner and honor our arrangements for my part my angry responses to her breaking the deals (pulling myself away) activated her victimization.

The hardest thing to admit about myself and now try to correct in me is that because she often used sex as the conflict point and also the lure back (which was usually unfulfilled), I acted like a textbook male stereotype and blindly enforced bad behavior. Why, because I was afraid I wouldn't get the intimacy I wanted with her, motivated by personal desire and not the best interests of us both.




So you say "We teach people how to treat us by the behavior we accept from them"

Yes, we also teach them how we can be manipulated.

I think I could have had different not guaranteed success but better results if I followed these thoughts you've outlined.

This is a not an uncommon problem in many marriages when the relationships is breaking down.  

Have you seen the "four horsemen" article on our blog:

Predictable Patterns of Marriage Breakdown

Mark Dombeck, Ph.D.

Source: www.mentalhelp.net/poc/view_doc.php?type=doc&id=9457&cn=289

According to Mark Dombeck, Ph.D., Director of Mental Help Net and former Assistant Professor of Psychology at Idaho State University, there is no single reason why a relationship begins to break down. However, once a relationship does start to break down, there is a predictable sequence of events that tends to occur. Highly regarded psychologist and researcher John Gottman, Ph.D. suggests that there are four stages to this sequence which he has labeled, "The Four Horsemen Of the Apocalypse".

Stage One The first stage of the breakdown process involves intractable conflict and complaints. All couples have conflicts from time to time, but some couples are able to resolve those conflicts successfully or 'agree to disagree', while others find that they are not. As we observed earlier, it is not the number or intensity of arguments that is problematic but rather whether or not resolution of those arguments is likely or possible. Couples that get into trouble find themselves in conflicts that they cannot resolve or compromise upon to both party's satisfaction. Such disagreements can be caused by any number of reasons, but might involve a clash of spousal values on core topics such as whether to have children, or how to handle money.

Frequently, couples assume that misunderstandings are at the root of their conflicts. "If my spouse really understood why I act as I do, he or she would agree with me and go along with what I want", is a commonly overheard refrain. Acting on this belief, spouses often try to resolve their conflicts by repeatedly stating and restating their respective rationals during disagreements. This strategy of repetition usually doesn't work because most of the time couple conflicts are not based on misunderstandings, but rather on real differences in values. When this is the case, stating and restating one's position is based on a mistaken premise and can only cause further upset.

Stage Two In the second stage of the breakdown process, one or both spouses starts to feel contempt for the other, and each spouse's attitudes about their partner change for the worse. For example, initially each spouse may have mostly positive regard for their partner and be willing to write off any 'bad' or 'stupid' behavior their partner acts out as a transient, uncommon stress-related event. However, as 'bad' or 'stupid' behavior is observed again and again, spouses get frustrated, start to regard their partner as actually being a 'bad' or 'stupid' person, and begin to treat their partner accordingly. Importantly, the 'bad' behavior that the spouse demonstrates doesn't have to be something he or she actually does. Instead, it could be something that he or she doesn't do, that the spouse expects them to do (such as remembering to put the toilet seat down after use).

Conflict by itself doesn't predict marriage problems. Some couples fight a lot but somehow never manage to lose respect for each other. Once contempt sets in, however, the marriage is on shaky ground. Feelings of contempt for one's spouse are a powerful predictor of relationship breakdown, no matter how subtlety they are displayed. In a famous study, Gottman was able to predict with over 80% accuracy the future divorces of multiple couples he and his team observed based on subtle body language cues suggesting contemptuous feelings (such as dismissive eye-rolling). Contempt doesn't have to be expressed openly for it to be hard at work rotting the foundations of one's relationship.

Stage Three Most people find conflict and contempt to be stressful and react to such conditions by entering the third stage of breakdown, characterized by partner's increasingly defensive behavior. Men in particular (but women too) become hardened by the chronicity of the ongoing conflict, and may react even more acutely during moments when conflict is most heated by becoming overwhelmed and "flooded"; a condition which is psychologically and emotionally quite painful. Over time, partners learn to expect that they are 'gridlocked'; that they cannot resolve their differences, and that any attempts at resolution will result in further overwhelm, hurt or disappointment.

Stage Four Rather than face the pain and overwhelm they expect to experience, partners who have reached this third 'defensive' stage, may progress to the forth and final stage of breakdown, characterized by a breakdown of basic trust between the partners, and increasing disengagement in the name of self-protection. Like a steam-valve in a pressure cooker, the partners start avoiding one another so as to minimize their conflicts. Gottman calls this final stage, "Stonewalling", perhaps after the image of a partner hiding behind a stone wall designed to protect him or her from further assault. Unfortunately, there is no way to love your partner when you are hiding behind a wall to protect yourself from him or her.

The "four horsemen" breakdown sequence plays out amongst the backdrop of partner compatibility. Basically compatible partners may demonstrate a whole lot of conflict, but they don't often become contemptuous and angry with their partners, because there are by definition few things that they will disagree upon. In contrast, partners who start out with incompatible goals, values or dreams are far more likely to get into seemingly irresolvable conflicts. Also, once the process of contempt, defensiveness and avoidance begins, small incompatibilities can become magnified as spouses pursue other interests as an alternative to conflict.

I hadn't seen the article thank you. I don't feel like it was contempt as described here though. I've certainly experienced those stages in the non relationships I've had. This was a different sort of feeling, like the key components, goals, values were there but an inability to execute on discussed and agreed upon resolutions.

That was my experience at the end too SunflowerFrields, I called out the boundary violations and how it hurt me very calmly, the return was "When I get what I want, you'll get what you want". Unfortunately her demand was a whole leap in return for the step I was requesting (to me at least). I think scale can be a factor, working toward a goal in small steps can trigger if there is expectation it's certainly against the impulsive nature on big decisions mine displayed (like marriage/kids).

That sort of reaction of "When I get what I want, you'll get what you want", makes the relationship seem all about ends to means rather a mutual journey.

I think only a therapist could step in as a third party to resolve this sort of battle of will and restore self & mutual respect. My pwBPD could outmanuever me emotionally anytime just like I could to her rationally, very different channels.

Hi there

Forgive me if I am asking questions which have been covered elsewhere - and do feel free to point me to older threads - but I am curious to know if anyone has any practical or theoretical knowledge of the comparative benefits of contrasting therapeutic approaches to PDs. I had a brief relationship with a man with PD traits last year but also believe that I may have a family member who is dealing with this issue - that's where my own interest comes from.

I have read a little about DBT and my own limited understanding of it suggests that it is a form of 'deep CBT' - a kind of mental and emotional retraining that allows the brain to step in and check unhelpful emotional responses when they are triggered. But it also seems as if it works on quite a profound level and can help people learn to understand the negative emotional effects that their behaviours have on others.

I also have some acquaintance with long term analysis through the experiences of a friend. I gather that this is a process that requires multiple sessions each week - often for many years - and aims to help adults who may not have achieved full emotional development as children to actually unpick the 'false selves' that they have erected to protect their 'undeveloped' selves  - to relive their childhood emotions - and to slowly rebuild a stronger sense of adult self from that point.

I was then also musing on Buddhism. A philosophy which seems to encourage us all to let go of too strong a sense of 'self' and to engage rather in a wider 'universal' identity that goes beyond any sense of separateness.

I tend to believe that in most situations it's unwise to look for a 'one size fits all' solution to any problem. For example I gather there are as many 'ideal ways to teach literacy' as there are children in a class - we all have different 'learning styles'.

But I would be interested to know a bit more about how each of  these approaches (DBT, long term psychoanalysis and following Buddhism) have brought  help and relief to people suffering from a PD.

Thanks for kicking this off anew, WWT!

I would add to your questions: the issue of constructing a "self."  Buddhist approaches, on which aspects of DBT are modeled, seem to de-emphasize the self and the need to differentiate.  Whereas many analyses of BPD dysfunction emphasize the lack of a stable sense of self not derived from others; and when you read, e.g., The Buddha & the Borderline, it's clear that the recognition and building of a self that is generated from the inside & not borrowed from someone else is a key step toward the author's recovery (though she uses both DBT and Buddhist study).  Any thoughts on whether BPD recovery involves relinquishing the need for a separate self or defining one?  Or is there a third way?

What do people here think of in regard to various ways for people with BPD and anxiety traits to best deal with their childhood traumas which may be the root cause of their unconscious fears today? What do you think of Hypnotherapy, ETF or EFT ("Emotional Tapping", and / or Neuro Linguistic Programming (NLP) options?

Hello Troyman,

In regards to hypnotherapy... .  I did some research and read a book by a very successful hypnotherapist... .  wondering the same things for the pwBPD in my life.  The bottom line as I understand it... .  for hypnotherapy to work the patient must be willing and believe that the therapy will work.  If they do it with reluctance and faithlessly it won't be successful.

lbj

Thanks, LBJ. Your points are quite valid. As with any treatment process chosen, the odds may be much higher if the patient believes it may work for them (aka "The Placebo Effect" since all forms of healing may begin first in the mind.

I have one more question in regard to this same topic:

If many top BPD specialists allege that childhood traumas (lack of bonding issues, emotional, physical, and / or sexual abuse, etc.) may be the true catalyst for a person's BPD traits later in life, then what percentage of people with ADMITTED BPD traits may truly recall their one or multiple childhood trauma events which impacted them so deeply at their core?

Obviously, we all repress conscious or unconscious childhood memories to varying degrees. I have yet to see a decent study on the percentage estimates of pwBPD traits who could clearly recall that their childhood traumas may be the true catalyst for their BPD traits as adults more so than their partner, children, parents, friends, co-workers, or others whom they "split" in present times. Are the figures closer to 25%, 50%, 75%, or higher?

If I understand correctly, you're wondering how many people who have BPD traits can link them back to a definitive cause during their childhoods. Is that right? I haven't seen any studies, but I've seen many posts on the boards from children of BPD parents who can name many specific traumatic incidents that outline BPD behavior from their parents. It's more common for children of BPD parents to have BPD traits than to not have any BPD traits.

Keep in mind that even if people with BPD traits can recall single incidents where they were traumatized, for many of us who grew up with BPD parents, we were exposed to BPD behavior constantly. We may not have recognized this behavior as unusual. Some of us picked up these traits unknowingly as we grew up. It's possible that there was no single incident that brought on the BPD traits in us, but repeated and consistent BPD behavior.

I'm curious now--are you concerned about your sons' well-being?

Thank you, Geeky Girl. You answered my question very well. I was wondering if a pwBPD traits today may recall their true childhood trauma event or events which deeply affected their Core Being even today as adults (i.e. one traumatizing abuse event, years of overwhelming anger and rage, etc.).

In regard to my own children, I have studied numerous ways to offset any anxious, controlling, blaming, or vindictive behaviors primarily to keep them healthy and happy.

Again, I help lead health support groups and my friends come to me for health advice on a weekly basis (which includes many friends with BPD and anxiety traits) as I have studied health topics in depth for well over 34 years. Since I am a lifelong "Bookworm" too who played lots of sports, I grew up reading lots of "Power of Positive Thinking" type books from people such as Norman Vincent Peale, Og Mandino, Dale Carnegie, Anthony Robbins (he uses a lot of NLP teachings), Dr. Wayne Dyer, and many others.

This positive mindset that obstacles are just temporary challenges which we either run over or around makes dealing with people with BPD traits so absolutely frustrating because I believe that ANYTHING may be cured or overcome by both our Immune System and our Mind. I know several terminal cancer patients who were cured back when their own Oncologists sent them home to die after they followed some of the natural health treatments which I base half of my diet on today for prevention and overall good health.

My Dad instilled in me as a very young boy to just "go for it, learn as I go, and that failure will just be a form of teaching for me" (or "I fail if I don't try something new" which is about the exact opposite of people with BPD traits.

Fortunately, I have yet to see any BPD traits with my children. Yet, I clearly see it in my ex's Family Tree. Ideally in a positive way, "For every action in life, there may be an equal and opposite reaction."

As I continually say and write quite often, we have but two core emotions in life - Love and Fear. All other feelings are just aspects of these two core emotions. Yet, Love is much more powerful than FEAR ("False Evidence Appearing Real".

Fear weakens us and zaps our energy while Love, in turn, energizes us to NEVER give up. Since we are primarily "Energy Beings" at our true core, then bet on the people motivated by the more energizing Love to prevail one way or another.

Hi all,

Sorry I'm quite new here and I didn't have time to read many boards yet, but I just read this on another website :

Question: What is the Borderline Personality Prognosis

I have been diagnosed with BPD. Does this mean I will have it for the rest of my life?

Answer: Most likely, no, you will not have BPD for the rest of your life. At one time, experts did believe that BPD was a life sentence; they thought that BPD was not likely to respond to treatment and that BPD was always chronic and lifelong.

Now, we know that this is a complete myth. Research has shown that almost half of people who are diagnosed with BPD will not meet the criteria for diagnosis just two years later. Ten years later, eighty-eight percent of people who were once diagnosed with BPD no longer meet criteria for a diagnosis.

In addition, there are now a number of treatments that have been proven to be effective for reducing the symptoms of BPD. So, with treatment, the disorder may remit much more quickly."

This is VERY optimistic compared to what I read here. Could you tell me what you think about that cuz I'm a little bit lost now.

Thanks in advance.

I completed NAMI's Family to Family program several months ago.  This is an excellent program in which to learn about the more common "mental illnesses", i.e. bi-polar, schizophrenia, schizo-affective disorder, depression, anxiety, paranoia, etc.  However, I was the only person in a group of 20 with a BPD family member. When we had mental health professionals as guest speakers, and I would ask questions about BPD, they would just say something along the lines of... .  "Oh that is really difficult.  Personality disorders deal with that part of a person that actually MAKES them WHO they are, although BPD is usually accompanied by associated disorders like anxiety, depression, schizo-affective traits, etc. which are more readily treatable.  Behavior modification MIGHT be the only treatment available."   ?

That was it.  They had little else to recommend and seemed uncomfortable discussing BPD. Perhaps they did not feel qualified to do so, I am not sure.  I got the message loud and clear that BPD IS unique... .  it is very difficult to diagnose, very difficult to live with, and even more difficult to treat.   It is separate from other mental illnesses but is often combined WITH them, and the boundaries between them constantly blur.

NAMI helped me to understand the associated illnesses that often accompany BPD, but finding your website has been a Godsend.  These two resources have helped me so much.  I have read extensively, and sharing the real-life experiences of other BPD family members is very reassuring.  We are not crazy! We are dealing with a very serious, extremely frustrating illness in a loved one.  It affects not only the BPD sufferer but anyone who shares their life, regardless of whether the relationship is as an intimate soulmate or casual acquaintance.   

Thanks for being here.

PS   I just learned about another program through NAMI called Family Connections that deals SPECIFICALLY with BPD.  I will have to check that out.  I hope it is available in my town.

Can therapy really change people with BPD?

I realize my experience is probably a little rare even on these boards, since my exBPD was diagnosed as well as attending therapy on a long term basis... . but still she showed ALL the BPD traits without any sign of getting better... .

IamDevastated,

My Ex was in therapy, was religious about meds,  committed to getting better and I personally saw her working her butt off trying to do things a different way.  She had and will always have my complete respect for the bravery she displayed in doing battle with her demons.

That being said, she didn't always win her battles.  And of course part of the disorder is the extinction burst.  As she was trying to subdue a behavior it often became dramatically and visibly worse.

I am convinced that with time my Ex will get there.  I also know that I am not the person to accompany her on the journey.

babyducks

There is a thread called success stories on the Staying Board with feedback from posters; it's starts off with Steph's story of her husbands recovery from BPD.

It's common for things to get worse before they get better.

Relationship is a major trigger for this illness. It would require a lot of detachment, self care, and work on codependent traits for a partner to survive or stay through a long healing journey. There are success stories and people do get better; that's why there is evidence based treatments today. But it's not easy, it takes a long time and a huge commitment. If addiction or other mental health issues exist, that also complicates treatment outcome.

So, no, it would not be accurate to conclude an individual failure means there is no successful treatment for anyone w/BPD. Even with BPD, people are still unique individuals, with their own unique strengths and weaknesses; the disorder is also on a spectrum in terms of severity.

I'm sure many relationships do not not survive the journey, as it's an incredibly difficult one with no guarantees that even a successful outcome means a great relationship. if a person did successfully make it through treatment, they may not even want to be in a relationship for a while. Someone recovered from BPD may not do the idealization or intense mirroring that tends to draw romantic partners to them like bees to honey.  Things would be quite different.

One year of therapy is really not very much. I would expect 2-3 years at least of a therapy targeted to symptoms of BPD. With additional maintenance as follow up.

My ex has been in T for about 8 years. He has improved a ton with anger management and interpersonal skills in general. But intimacy... . that's where things are still dicey.

I've recently seen very good reports on Schema therapy, even a report somewhere from last year, while DTB seems more effective for those borderlines harming themselves often or with suicidal ideas.

I think motivation and empathic support are very important for the person in therapy.  I think some borderlines may just lie about their 'big' motivation as they lie about anything else due to the borderline.

The stories referred to by MaybeSo is found here : https://bpdfamily.com/message_board/index.php?topic=113820.0

Someone posted somewhere earlier that therapy is actually emotionally growing up to an adult.  And I think it is, but think at the difference when someone goes in therapy at age 18 or age 40.  I think there's a lot more work to do in the last case !

Also medication seems to be able to play an important role to ease down some of the symptoms and better the results of the therapy according to MD Robert O Friedel :

www.BPDdemystified.com/treatments/medication

Still therapy seems to take at least 2 - 3 years to be successful... .

Reg

Maybe 'triggers' isn't the right term for the title, or is it?

With Alcoholism, there's "rock bottom". With drug addiction, there's intervention. For so many illnesses and disorders, there's identifiable cause-and-effect catalysts that initiate the recovery process. In the course of swallowing a supertanker worth of information lately on cluster B disorders, including reading blogs of recovering sufferers, it seems there's little to no information regarding what the impetus is for recovery.

I would think that would be a prime area for research, no?

I think the defining moment may be different for each person, as it is with anyone who feels their life is out of control and wants to change it.  Here is an interesting read with a video link about Marsha Linehan, an expert in the BPD 'world', and who had opened up about her own diagnosis as a pwBPD:

https://bpdfamily.com/message_board/index.php?topic=149362.0

Here is a link to the original article in the NY Times: www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=all&_r=0

Perhaps this might give you some insight into your question.

Hi. I've read about DBT and a lot of it seems to be directed at the "raging," impulsive, self-injuring, suicidal type of Borderline case.

But what if those three symptoms are the one missing from my uBPDex? He's a "quiet" type. He has all the other symptoms, but not the dangerous violent ones.

Does DBT still address the other things like identity-fragmentation, sexual ambivalence, fear of commitment and intimacy, abandonment/engulfment cycles, unstable relationships, problems with decision-making and agency, lack of boundaries inner and outer?

DBT is about learning the coping skills to deal with intense emotions.   When we are emotional thinkers we react and not respond, we damage our relationships, professional lives, self image, etc... .

As skills are learned and used we respond rather than react.  The successful outcome can positively affect all aspects of ourselves and our relationships.

I found this study (well, a commentary on it). I was shocked. I asked some senior folks here and they all said it was a well established by "McLean Hospital [which] is the preeminent metal health facility in the world." There have been discussions of it previously (https://bpdfamily.com/message_board/index.php?topic=117735.0)but not for a long time.

Predictions of the 10-year course of borderline personality disorder.

Amarine, MC, Frankenburg, FR, Hensen, J, Reich, DB, and Silk, KR. "Predictions of the 10-year course of borderline personality disorder." American Journal of Psychiatry, 163:827-832, 2006.

Basically it says that half of dX pwBPD with not meet the criteria in two years. 80% in ten years. It just goes away?  This is without therapy.

I made some really good strides at detaching. I felt very confident.

Then I found this. Thoughts of  "perfect, she can do her thing for a while. I'll take the time to heal, learn skills, and sooner or later we could work this out." Stupid thoughtsbut they surface again and again.

I am hoping by this discussion I will be able to detach from those thoughts.


I was going on BPD being permanent unless one did the work my uBPDex is clearly not able. This study suggests something else. Does that change anything for you?


I would also like to know if there are any studies on the rate of BPD amongst older populations.

Staying with our platform that we are here to learn from the expert body of literature, what can we learn from this?

The study was conducted by a worldwide center of excellence - Harvard University.  The data was collected started in the 1980's.  Some of the data was not readable and didn't end in the study findings.  

All subjects were initially inpatients at McLean Hospital in Belmont, Mass. In terms of baseline demographic data, 233 subjects (80.3%) were women, and 253 (87.2%) were white. The average age of the borderline subjects was 26.9 years (SD=5.8), their mean socioeconomic status was 3.4 (SD=1.5) (in which 1 was the highest and 5 was the lowest), and their mean Global Assessment of Functioning Scale score was 38.9 (SD=7.5), indicating major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

A substantial number of factors were found to be associated with a good long-term

outcome:

• high IQ (4, 5),

• being unusually talented or physically attractive (if female) (4),

• the absence of parental divorce and narcissistic entitlement (7), and

• the presence of physically self-destructive acts during the index admission (5).

A larger number of factors were found to be associated with a poor long-term outcome:

• affective instability (5),

• chronic dysphoria (2),

• younger age at first treatment (2),

• length of prior hospitalization (5),

• antisocial behavior (4),

• substance abuse (4).

parental brutality (4),

a family history of psychiatric illness (2), and

a problematic relationship with one’s mother (but not one’s father) (6).

The youngest did better than the older participants

Those with no prior psychiatric hospitalizations

Those with no childhood sexual or physical abuse;

Those with no family history of mood or substance use disorder

Those with absence of PTSD and absence of anxious cluster personality disorders

Those with good psychosocial functioning (a good vocational record).

It was noted that the severity of borderline psychopathology was not a significant predictor of time to remission.

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

It's a good idea for people to read the entire study at the link posted - not just the summary.

This one is from 2012 so more data is included. Remission rate is still high, practically in line with other disorders - it makes me happy for pwBPD. Recovery rate is, however, practically half of that of other disorders. Triggering back into the disorder is also notably higher in BPD patients than other disorders.

Another very important note is that all studied patients were inpatients, that is people who either willingly or with the help of friend/family/authorities commit to treatment. Authors are , at the end of the study, optimistic about the degree to which the disorder affects other sufferers:


This study, while limited to inpatients, holds some promise.

However, it appears that the study speculates that non-hospitalized patients are less severe in symptoms and negative social behaviors (behavior even with one person is still a social behavior). That practically means that they discard the severity of BPD in high-functioning individuals.

hi,

I got the information from a lecture of a a psychotherapist who works at the Dr Guislain Psychiatrisch Centrum (http://www.guislain.be/), in Ghent (Belgium), her name is Ria Schoutteet.

Schoutteet works with systemic therapy. She confirmed that the percentages I mentioned here above are official numbers but I don't know more about it.  I did not find much additional information on the net.

If ever I get my BP into therapy with her I might get you some more information but that won't be too soon I'm afraid.

here are some percentages that I heard in a recent talk who works mainly with young patients

- 2% of the entire population has BPD

- 20 % of the population in psychiatric institutions suffers from BPD

! these are her statistics on the patients who are in treatment and who do not have comorbity with other disorders/ addictions:

- after 3 years therapy: 60% is still diagnosed with BPD

- after 15 years therapy: 25 % is still diagnosed with BPD

what are your thoughts on these statistics ?

I like the idea that for 40 % of the patients therapy apparently works very good in only 3 years time... . 

she said that preferably patients should start with therapy before they are 30, they need to be motivated and usually they get ambulant therapy , because institutionalising can work contra-productive.

also she mentioned:

- BPD-traits/instabilities  lessen when people get older

- relationships stabilise and they start to function better

- the risks on suicide lessen when patients get older

this is allready the second time that I heard a specialist on BPD testify and they always sound so positive... whilst on these boards people usually doesn't sound very optimistic... . 

personally I am dealing with a pwBPD who unfortunately is not willing to get therapy and who got stuck in his way of life and his addictions for too long allready :-(

but I can't help that I keep the faith after hearing these good stories... . 

Contrary to this, the follow-up studies came to a conclusion that interpersonal relationships were the least likely to improve.

The last interpersonal feature to remit, that is affective consequences of being alone, has been identified in clinical theory as a core feature in BPD (Modell, 1963; Winnicott, 1965; Masterson, 1972; Adler & Buie, 1979; Gunderson, 1984). Modell, Winnicott, and Masterson described the processes relevant to the developmental milestones of separation and acquiring the ability to be alone. Adler and Buie (1979) emphasized the specific inability of those who do not achieve such milestones to conjure up or evoke positive and soothing representation of others while alone (i.e., failure to achieve object constancy). Gunderson (1996) defined this as a core problem which renders borderline individuals more reactive to interpersonal slights, which in turn explains the rapid fluctuations in their interpersonal phenomenology. These descriptions of the intolerance of aloneness and failure of object constancy associated with BPD have been confirmed empirically (Richman & Sokolove, 1992) and appear to be reflected in the most persistent and stable interpersonal feature of BPD found in our study.

www.ncbi.nlm.nih.gov/pmc/articles/PMC3222950/

Just wanted to mention that my dBPDbf is receiving schema therapy. It's funny (and warming) to notice his progress. A few weeks ago he got into a very hurt kind of rage, quite desperate. Right when I didn't know what to validate/say to him anymore, he said: "My T says I am in the 'hurt child modus' when I am acting like this and that I should think how my grown up version would deal with the situation."

Jeebers you can't imagine what that meant to me.

He speaks up for himself as well - telling me to trust him, telling me what he needs. He seems to be able to voice his needs in a better way now.

He's been in this for 1 full year now (+6 months of prior ADHD therapy)... .I think they're slowly getting deeper. He had to bring pictures from his childhood the other day so I guess they started digging. I'm hopefull about the upcoming two years :).

hi ziniztar,

glad to hear this :-)

just curious: what made your bf choose schema therapy and not DBT ?

any specific motivations for that ?

is 3 years an average estimated time for this therapy ?

Not that I know of, but I'm not sure he is aware of the type of therapy he gets. We live in NL and schema is kind of big here because a renowed professor who has done a lot of research on it is part of a Dutch university.

The three years is something I read everywhere. His T has not mentioned anything about it as I think it can be devastating to hear that you need at least 3 years of therapy. When I mentioned it to him once he was shocked - obviously not something he had heard of before.

He also has ADHD so maybe the comorbidity lead to schema, as I think it relies less on structured behaviour and more on insight, re-parenting, re-building. Due to his ADHD impulsivity or poor executive control is his biggest challenge... DBT may be lesser appropriate in that case?

Good reference, BorisAcusio.

|iiii

The studies conclusions were:

Behaviorally oriented features, such as... .

• recurrent breakups,



• sadism,



• demandingness,



• entitlement,



• regression in treatment, and



• boundary violations,

... .remitted quickly and were rare at the end of follow-up.

www.ncbi.nlm.nih.gov/pmc/articles/PMC3222950/

This is pretty promising.

The interpersonal features slowest to remit were affective responses to being alone, active caretaking, discomfort with care, and dependency.

www.ncbi.nlm.nih.gov/pmc/articles/PMC3222950/

Also true.

Skip, that article was very useful! I love reading scientific stuff about this, gives me a sense of control and understanding I guess.

I read that active caretaking is one of the toughest to disappear... .as a woman with a clear desire to become a mom at some point... I was wondering what is meant by active caretaking. Of others? Which is difficult because of the strong emotions inside that will probaly not leave and therefore leave the pwBPD pre-occupied with his/her own affects?

Can someone please shed some light on this:

How therapy works in the borderline mind?

How can someone who has lived by the all black/white rule can possibly change the way they perceive the world? Is there some kind of manual for this? How long does it take for an untreated patient to achieve results? Is it very effective? What will the natural evolution of the disorder be if the pwBPD doesnt take any therapy?

Will the therapist use hypnosis as a tool to discover what happened to the patient in his childhood?

Was the disorder "dormant" through the pwBPD's life and the suddenly manifested itself?

DBT or SCHEMA, which one is best?

Hi Painted,

I'd be happy to share some experience from when I was more "borderline"; private message me if you want.

Your questions could be hard to answer objectively, since each person's circumstances are the severity of their problems vary. For example, if you have the question, "How long does it take for an untreated patient to achieve results?" that would depend on the severity of the person's problems, their willingness to seek help, the quality and intensity of resources available to help them, among other factors. So it would vary greatly for individuals. With DBT or schema, that might be partly a matter of personal preference, or it might depend on how good the clinician is who is providing the treatment, again, among many other factors.

My interest is in psychodynamic therapy, of which Kernberg's Transference-Focused Therapy would be the closest among the kinds discussed so far.

At the bottom of this page there are some links to some of their research studies - www.transferencefocusedpsychotherapy.com/borderline-personality-disorder-TFP-research.php

I also think you can learn a lot from reading extended case studies. In another post I shared how I'd read about these in books by various authors, for example Jeffrey Seinfeld, James Masterson, and Vamik Volkan. In this way you can get a sense of the "borderline" beyond the label, seeing them as an individual, and understand better what problems they started with and what progress they made by the end of treatment. When you lump loads of different people together in a study, you are talking about averages or aggregates, and these may not give you accurate information about any individual.

With my two friends who are borderline, I am encouraging them to do psychodynamic therapy long-term. I think it usually takes at least a few years to achieve significant change; that is from my own experience.