One of the most memorable experiences I had when I was doing inpatient psychiatry work over 20 years ago was caring for a young woman who remained in the hospital for 10 months due to depression and suicidal ideation. She also had Borderline Personality Disorder (BPD) and the general consensus among staff at the time was that her condition was hopeless and she would never get better. However, she did get better and we now know the perception of BPD as having a bad prognosis over time is incorrect. Multiple studies have confirmed that substantial improvement occurs and that, in fact, BPD has the best prognosis of all major psychiatric disorders. In this next article, I will present an overview of BPD and the keys to a good outcome.
Personality Disorders develop when people are stuck in ways usually acceptable only for younger people such as teenagers. The essence of BPD comes down to a triad of symptoms: 1) impulsivity, 2) mood instability, and 3) terrible views about oneself (self-image) and other people (interpersonal relationships). They tend to see people and situations as all good or all bad; this is called “splitting” in which there is an inability to see people or situations in shades of grey.
The biosocial theory behind BPD is: biological vulnerability + invalidating environment = emotional dysregulation. The invalidating environment is not about a harmful parent but more about a mismatch between parent and child. The deficits in emotional regulation include the inability to inhibit inappropriate behavior, the inability to self-soothe emotionally, and the inability to refocus attention.
BPD is by far the most common personality disorder diagnosis made in clinical settings (10% inpatient units, 20% outpatient clinics, and 3% of the general population). Borderline patients are prone to get overwhelmed under stressful conditions and tend to be more treatment seeking than other personality disorders. Borderline personality themes include: chaotic childhood, parental neglect, sexual abuse, fears abandonment, maintains self-destructive relationships, frequent suicidal ideation or gestures, and feels hurt by “all” past involvements. Glenn Close played a classic borderline personality in Fatal Attraction; other good movie examples are Girl Interrupted, Single White Female, Rachel Getting Married, Margot At the Wedding, and The Hand That Rocks the Cradle.
The optimal treatment of BPD is an integration of psychotherapy and pharmacotherapy. Borderline patients fare best with an eclectic, pragmatic therapeutic approach and there is no single treatment of choice. Major forms of psychotherapy include: dynamic therapy, dialectical behavior therapy (DBT), Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy, Mentalization, Schema, and Good Psychiatric Management. In recent years, DBT has been the most common treatment for BPD in the U.S. which includes 4 group skill modules: 1) mindfulness skills, 2) interpersonal effectiveness skills which helps with appropriate assertiveness, 3) emotional regulation skills to help with anxiety, and 4) distress tolerance skills to help not making a bad situation worse. Rage is a central problem and treatment will be smoother if the therapist can hold firm and stay in a mid-position between withdrawing or retaliating. Consistency helps foster a stable image of the therapist, the therapy, and ultimately the patient.
Another key to successful therapy of BPD is to help patients find meaningfulness and achieve spiritual restoration. Patients with BPD often get stuck in an angry and destructive obsession with obtaining revenge for childhood trauma. It’s a matter of helping reorient their values so they feel less hollow inside such as realistic self-fulfillment and investment in helping other people (“other-orientedness”): family, friends, the community, and society in general.
Now the good news. Studies have shown that roughly two-thirds of young patients with BPD begin to do quite well as they reach their thirties. In fact, upon 16 year follow up, 99% achieve remission of symptoms. With the help of psychotherapy and possibly medication, 60% recover with only mild residual symptoms, good occupational functioning, a circle of friends, and perhaps even a sustained intimate relationship. The difference between remission and recovery is that remission is about less symptoms while recovery is about less symptoms plus improved social and occupational functioning. The goal is not just to have less symptoms but for people to achieve a life worth living.
One study done by Dr Michael Stone was able to identify predictors of good outcome. Nearly every patient who had even one of the following favorable characteristics did quite well:
Very high intelligence. Patients with an IQ of 135 or more had a good outcome no matter how difficult their personality because they got good jobs.
Artistic talent. Dancers, writers, musicians, painters—they all turned out well.
Obsessional traits. This translated into self-discipline, which helped patients handle solitude without becoming frantic.
Striking physical beauty in female patients. They were never at a loss for a rescuer.
Sticking with Alcoholics Anonymous. Roughly 20% in Dr Stone’s study had an alcohol problem. Those who enrolled in AA and persevered with the program had a uniformly superb long-term fate.
Over time with treatment, most of the core symptoms improve rapidly including impulsivity, interpersonal problems, and cognitive issues. The one issue that remains the stickiest and tends to stay around the longest is mood instability; while this symptom is not life threatening it does prevent people from moving forward in their lives such as with work or close relationships. The challenge is that it’s hard to change one’s biological vulnerability or temperament but therapy revolves around ways to get around it and even reframing it: to be a full-bodied human being includes a wide range of emotions which we shouldn’t be ashamed of—if having some anger or feistiness is a part of it along with a genetic tendency to have that intensity, there are ways to use it productively.
The overall goal in therapy is for people is to achieve a more integrated sense of self and others which is about acknowledging any negative emotions but to eliminate extreme reactions and to live with the complexity of life and not give up during the rough spots. An example in my current practice is a woman in her mid-40s with a history of Borderline Personality who recently had a very hard day at work and contacted me to let me know she felt like quitting her job and going on disability. However, before I could even prompt her, she was able to catch herself with self-reflective awareness that it was only one bad day of work and “tomorrow is a new day”—that’s a great sign of healing and integration when a person can still get triggered but rather than get caught in a familiar and outdated, extreme reaction is able to sit with a complex mixed view of the situation.
In summary, BPD had a bad reputation at one time due to many inpatients having this diagnosis, uncertainty on how to treat it and lack of long-term studies until recent years. It’s important to acknowledge that reputation was unfair and we need to reduce the stigma with this disorder. If you or someone you love is struggling with BPD, it can be easy to feel despairing about the current symptoms and the effect it is having on that person and the people in that person’s life. However, the take home message is that there are good resources out there and with consistent treatment, time, patience, and compassion, BPD is a very treatable condition that in most cases has a stable remission. Perhaps a good metaphor for BPD would be like growing up, once you get out of adolescence, you don’t reenter it very readily.