Two main findings have emerged from this study. The first is that only half of the borderline patients in this study experienced a recovery from borderline personality disorder, which we defined as requiring a two-year symptomatic remission and the attainment of good social and vocational functioning. This finding stands in contrast to the fact that over 90% of borderline patients experienced a two-year symptomatic remission and 86% experienced a four-year symptomatic remission. Taken together, these results seem to suggest that good social and vocational functioning is more difficult to attain than substantial symptomatic reduction; a formulation first clearly articulated by Skodol et al. (10
). These results also seem to suggest that most borderline patients who achieve a two-year remission from borderline personality disorder also achieve a remission lasting at least four years or two consecutive follow-up periods.
It might be argued that either of our definitions of remission could actually be seen as recoveries, particularly sustained remission lasting four years or more. This is so because studies of axis I disorders often describe remissions or even recoveries in terms of weeks and months of decreased symptomatology (18
). However, our definition of recovery, which includes good social and vocational functioning as well as two years of symptomatic remission, is more consistent with what patients and their families believe is the goal of treatment and the desired outcome of maturation or at least, the passage of time.
This set of results is consistent with clinical experience. More specifically, many patients exhibit far fewer borderline symptoms as time progresses; a result found in a recent 10-year report from the Collaborative Longitudinal Personality Disorders Study (20
). However, their psychosocial functioning remains or becomes impaired over the years. Given this, it is not surprising that only half of borderline patients attained all three aspects of recovery from borderline personality disorder: symptomatic remission and the attainment of both social and vocational competence. However, it is sobering that only half of borderline patients achieved a fully functioning adult adaptation with only mild symptoms of borderline personality disorder. Additionally, this set of findings suggests that the overall prognosis for many borderline patients is somewhat more guarded than the findings of the long-term follow-back studies conducted more than 20 years ago were thought to mean. However, this discrepancy is not surprising given the more thorough prospective assessments of the current study.
The second main finding is that recovery from borderline personality disorder was relatively stable, with only about 34% of those attaining such a recovery later losing one or more aspects of this multifaceted outcome. While this rate was very similar to the 30% rate found for symptomatic recurrence after a two-year long remission, it was twice the 15% found for loss of a sustained four-year long symptomatic remission.
In fact, each of the three rates of recurrence studied are lower than those found for common axis I disorders studied longitudinally, such a major depression (21
) or dysthymic disorder (18
). Additionally, the high rate of sustained symptomatic remission (86%) and the low rate of symptomatic recurrence after such a four-year long remission (15%) are two of the most optimistic findings about borderline personality disorder to date.
Taken together, the results of this study have implications for the treatment of borderline patients. While clinical experience suggests that clinicians are often aware that their borderline patients have trouble achieving a good overall long-term outcome, clinical experiences also suggests that their psychosocial deficits are rarely the focus of treatment. Rather the emphasis is on symptom reduction and management. Yet our results suggest that remissions are far more common than the good psychosocial functioning needed to achieve a good global outcome.
It would seem wise for those treating borderline patients to consider a rehabilitation model of treatment for these psychosocial deficits (22
). Such a model would focus on helping borderline patients to attain work, make friends, take care of their physical health, and develop interests that would help to fill their leisure time productively. And such an approach could be an added form of treatment and not one directly competing for primacy with a treatment focused on symptom remission.
If this rehabilitation approach was adopted and proved effective, it could limit the relatively high percentage of borderline patients supporting themselves on Social Security disability benefits (23
). It might also help to alleviate some of the feelings of worthlessness and failure that permeate the self-concept of many borderline patients who have failed to achieve the life that others and they themselves had once expected.
This study has a number of limitations. The first is that all subjects were initially inpatients. It may well be that borderline patients who have never been hospitalized are less impaired psychosocially and thus, more likely to attain a good global outcome over time. The second is that the majority of the sample was in treatment over time and thus, the results may not generalize to untreated subjects.
In terms of future studies, we plan on assessing time-to attainment of a Global Assessment of Functioning Scale score of 71 or higher when we have completed further waves of follow-up. In this way, we will be able to determine if our rates of this overall outcome are similar to the 16% and 42% found by McGlashan and Stone respectively in their long-term follow-back studies (1
Taken together, the results of this study suggest that recovery from borderline personality disorder combining both symptomatic remission and good psychosocial functioning seems difficult for many borderline patients to attain. These results also suggest that such a recovery once attained is relatively stable over time.
Ms. A was in her early 20s at the time of her index admission. She came from a middle class background marked by parental alcoholism and childhood adversity. She had had numerous prior hospitalizations and met criteria for co-occurring PTSD, panic disorder, and EDNOS. While the severity of her borderline psychopathology increased over the first two years of follow-up, she achieved a remission of BPD by the time of the four-year follow-up. Her psychosocial functioning also improved during this period as she worked steadily at a demanding job, saw friends regularly, and met her future husband. Her remission and recovery from BPD were stable throughout the next six years. She no longer met criteria for any axis I disorder. She continued in once weekly psychotherapy but no longer took any psychotropic medication. She is currently married, the mother of several children, and works outside the home on a part-time basis. She describes herself as happy and her family as a “treasure” for which she is very grateful. She is described by others as likeable and resilient.
Ms. B was in her mid 30s at the time of her index admission. She came from an upper middle class background and reports being subjected to extreme cruelty and violence during latency and adolescence. She had had over 10 prior hospitalizations and met criteria for nine axis I disorders, including mood, anxiety, somatoform, and eating disorders. She experienced a remission of BPD at four and six-year follow-up but she never recovered from BPD. While having friends, she never dated or worked. Rather, she supported herself through disability payments. She experienced a recurrence of BPD at eight and 10-year follow-up, which she attributed to the loss of a trusted member of her treatment team. After this loss, her physical health deteriorated. In addition, she no longer saw her friends on a regular basis. Rather, she spent most of her time either home alone or going to appointments with numerous medical specialists and mental health providers. She describes herself as permanently damaged, yet “hopeful” about the future. Others describe her as eager for connection but fragile.