TREATMENT: Cures and Recovery

[BPDFamily.com]

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?

[UmbrellaBoy]

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?

[lbjnltx]

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.

[Pecator]

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 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.

[BPDFamily]

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.







Augmenting Psychotherapy for Borderline Personality Disorder: The STEPPS Program

Kenneth R. Silk, M.D.

Am J Psychiatry 2008;165:413-415. doi:10.1176/appi.ajp.2008.08010102

The diagnosis of borderline personality disorder conjures up thoughts of helplessness and hopelessness. The helplessness and hopelessness reside not only in the patient but often in the treatment providers as well. A widespread belief that continues to exist among mental health professionals is that treatment does very little for borderline personality disorder patients. Yet they are very difficult to disengage from treatment. Therapists shy away from informing the patient that she has the diagnosis because to pronounce the diagnosis not only would be equivalent to a type of “death sentence” (as we used to be afraid of telling patients that they had cancer or schizophrenia), but it would also cause fear of the rage that the therapist is certain to encounter from the affectively dyscontrolled patient.

Much has changed in the last 10–15 years, but unfortunately too many therapists still feel that borderline personality disorder is untreatable and is a lifelong drain on the energy of the therapist, the psychopharmacologist, and the entire mental health system. While it is true that people with borderline personality disorder utilize mental health resources to a far greater extent than their 1%–2% prevalence would suggest (1), the idea that these patients never change or improve needs revision.

Even more surprising and myth-debunking is the number of well-designed controlled studies in support of effective treatment for borderline personality disorder patients. These studies, for the most part, are randomized controlled trials of therapies that range from cognitive behavior, such as dialectical behavioral therapy (4) and other more straightforward cognitive behavioral therapies (5), to psychodynamic and psychoanalytically based therapies, which include mentalization-based therapy (6) and transference-focused psychotherapy (7), to the blend of cognitive and dynamic therapies in schema-focused therapy (8). And not surprisingly, as therapies that appear to be effective emerge, there are now articles urging that patients be informed of their borderline personality disorder diagnosis (9). It is interesting that most of these interventions are in the nonpharmacologic arena, while psychopharmacologic treatment of borderline personality disorder remains unclear, uncertain, and in general unimpressive... .

[Skip]

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

[BorisAcusio]

Attainment and Stability of Sustained Symptomatic Remission and Recovery Among Patients With Borderline Personality Disorder and Axis II Comparison Subjects: A 16-Year Prospective Follow-Up Study

Mary C. Zanarini, Ed.D.; Frances R. Frankenburg, M.D.; D. Bradford Reich, M.D.; Garrett Fitzmaurice, Sc.D.

Am J Psychiatry 2012;169:476-483. doi:10.1176/appi.ajp.2011.11101550

www.ajp.psychiatryonline.org/article.aspx?articleid=1065354

Objective:  The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes.

Method:  A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R.

Results:  Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%–99%; range for axis II comparison subjects: 97%–99%) but not recovery (40%–60% compared with 75%–85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%–36% compared with 4%–7%; loss of recovery: 20%–44% compared with 9%–28%).

Conclusions:  Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

[coolioqq]

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 has some limitations. The first is that all participants were initially inpatients. It may be that borderline patients who have never been hospitalized are less severely ill symptomatically and less impaired psychosocially and thus more likely to remit more rapidly and attain a good global outcome over time. The second is that the majority of those in both study groups were in nonintensive outpatient treatment over time (28), and thus the results may not generalize to individuals who are not receiving treatment.

The results of this study suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder. Our findings also suggest that sustained remissions and recoveries are substantially more difficult for borderline patients to attain and maintain than for patients with other forms of personality disorder.

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.

[lemon flower]

hi,

I got the information from a lecture of a a psychotherapist who works at the Dr Guislain Psychiatrisch Centrum, 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... . 

[BorisAcusio]

- relationships stabilise and they start to function better

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/

[ziniztar]

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 .

[lemon flower]

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 ?

[ziniztar]

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?

[Skip]

Contrary to this, the follow-up studies came to a conclusion that interpersonal relationships were the least likely to improve[/color]

Good reference, BorisAcusio.



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.

[ziniztar]

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?

[PaintedBlack28]

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?

[BPDTransformation]

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.