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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Am J Psychiatry. Author manuscript; available in PMC May 1, 2013.
Published in final edited form as:
PMCID: PMC3509999
NIHMSID: NIHMS356404
Attainment and Stability of Sustained Symptomatic Remission and Recovery among Borderline Patients 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., and Garrett Fitzmaurice, Sc.D.
Address reprint requests to Dr. Zanarini, McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02478; phone: 617-855-2660; fax: 617-855-3580; zanarini/at/mclean.harvard.edu.
Objective
The first purpose of this study was to determine time-to-attainment of symptomatic remissions and recoveries of 2, 4, 6, and 8 years duration for those with borderline personality disorder and comparison subjects with other personality disorders; the second was to determine the stability of these outcomes.
Method
290 inpatients meeting both Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for borderline personality disorder and 72 axis II comparison subjects were assessed during their index admission using a series of semistructured interviews. The same instruments were readministered at eight contiguous two-year time periods.
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, those in both study groups ultimately achieved about the same high rates of remission (borderline patients: 78–99%; axis II comparison subjects: 97–99%) but not recovery (40–60% vs. 75–85%) by the time of the 16-year follow-up. In contrast, symptomatic recurrence (10–36% vs. 4–7%) and loss of recovery (20–44% vs. 9–28%) occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects.
Conclusions
Taken together, the results of this study suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder. They also suggest that sustained remissions and recoveries are substantially more difficult for borderline patients to attain and maintain than those with other forms of personality disorder.
Many clinicians still believe that borderline personality disorder is a chronic disorder that uses a disproportionate share of mental health services. This belief has held constant despite a quarter century of research suggesting that the course of borderline personality disorder is both more heterogeneous and for many, more benign, than generally thought.
In terms of empirical evidence, four large-scale, long-term, follow-back studies of the longitudinal course of borderline personality disorder were conducted in the 1980s (14). Only one of these studies assessed the remission rate of those borderline patients who were successfully followed (2). Paris and his colleagues assigned chart review diagnoses of borderline personality disorder to 322 former inpatients and found that 75% of the 100 borderline patients they traced a mean of 15 years after their index admission no longer met criteria for the disorder. However, all four studies assessed overall outcome and found that the borderline patients received a mean score of 63–67 on scales that were precursors to the Global Assessment of Functioning (14). This outcome is typically viewed as achieving a relatively good adaptation to the demands of adult life.
More recently, two NIMH-funded large-scale, prospective studies of the long-term course of borderline personality disorder—the McLean Study of Adult Development or MSAD (5) and the Collaborative Longitudinal Personality Disorders Study or CLPS (6) have published papers describing the 10-year outcome of their samples. In the McLean Study of Adult Development, it was found that 93% of the borderline patients achieved a remission that lasted at least two years but only 50% attained a two-year recovery, which was defined as concurrent symptomatic remission and good social and vocational functioning. In the Collaborative Longitudinal Personality Disorders Study, it was found that 85% of borderline patients achieved a remission lasting 12 months or more. In terms of overall functioning, about 20% of borderline patients attained a GAF score of 71 or higher for two months or more.
The current study, which is an extension of the McLean Study of Adult Development mentioned above, builds on our prior work in three important ways. First, outcomes for axis II comparison subjects are compared to those obtained by borderline patients. Second, we followed these two study groups over six additional years of prospective follow-up. Third, we assessed remissions and recoveries lasting 2, 4, 6, and 8 years as well as the symptomatic recurrences and loss of recoveries that followed these outcomes.
We have typically defined remission and recovery by a two-year time period. We decided to study longer remissions and recoveries because it is these lengthy periods of time that patients, their families, and the mental health professionals treating them are particularly interested in as they signify that stable change has occurred.
The methodology of this study has been described before (7). Briefly, all subjects were initially inpatients at McLean Hospital in Belmont, Massachusetts. Each patient was first screened to determine that he or she: 1) was between the ages of 18–35; 2) had a known or estimated IQ of 71 or higher; 3) had no history or current symptoms of schizophrenia, schizoaffective disorder, bipolar I disorder, or an organic condition that could cause psychiatric symptoms; and 4) was fluent in English.
After the study procedures were explained, written informed consent was obtained. Each patient then met with a masters-level interviewer blind to the patient's clinical diagnoses for a thorough psychosocial and treatment history as well as diagnostic assessment. Four semistructured interviews were administered. These interviews were: 1) the Background Information Schedule (8), 2) the Structured Clinical Interview for DSM-III-R Axis I Disorders (9), 3) the Revised Diagnostic Interview for Borderlines (10), and 4) the Diagnostic Interview for DSM-III-R Personality Disorders (11). The inter-rater and test-retest reliability of the Background Information Schedule (12) and of the three diagnostic measures (13,14) have all been found to be good-excellent.
At each of eight follow-up waves, separated by 24 months, psychosocial functioning and treatment utilization as well as axis I and II psychopathology were reassessed via interview methods similar to the baseline procedures by staff members blind to previously collected information. After informed consent was obtained, our diagnostic battery was readministered as well as the Revised Borderline Follow-up Interview—the follow-up analog to the Background Information Schedule administered at baseline (15). Good-excellent follow-up (within a generation of raters) and longitudinal (between generations of raters) inter-rater reliability was maintained throughout the course of the study for variables pertaining to psychosocial functioning and treatment use (12). Good-excellent follow-up and longitudinal inter-rater reliability was also maintained for both axis I and II disorders (13,14).
Definition of Remission from Borderline Personality Disorder or Another Axis II Disorder
We defined remission as no longer meeting study criteria for borderline personality disorder (Revised Diagnostic Interview for Borderlines and DSM-III-R) or another personality disorder (DSM-III-R) for a period of two years or more (or one follow-up period). We also studied remissions lasting four, six, and eight consecutive years (or two, three, or four consecutive follow-up periods).
We selected a Global Assessment of Functioning score of 61 or higher as our measure of recovery because it offers a reasonable description of a good overall outcome (i.e., some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships). We operationalized this score to enhance its reliability and meaning. More specifically, to be given this score or higher, a subject typically had to be in remission from his or her primary axis II diagnosis, have at least one emotionally sustaining relationship with a close friend or life partner/spouse, and be able to work or go to school consistently, competently, and on a full-time basis (which included being a houseperson).
The Kaplan-Meier product-limit estimator (of the survival function) was used to assess time-to-2-(4, 6, and 8) year remissions and time-to-2-(4, 6, and 8) year recoveries from borderline personality disorder or another personality disorder. We defined time-to-attainment of these outcomes as the follow-up period at which these outcomes were first achieved.
The Kaplan-Meier product-limit estimator was also used to assess time-to-recurrence after remissions lasting 2, 4, 6, or 8 years and time-to-loss of recovery after recoveries lasting 2, 4, 6, or 8 years. We defined time-to-recurrence or loss of recovery as the number of years after first attaining these outcomes.
Finally, Cox proportional survival analyses were used to compare the borderline patients and axis II comparison subjects in terms of these time-to-event outcomes; these analyses yield a hazard ratio (HR) and 95% confidence interval (95%CI) for the comparison of the two diagnostic groups.
Two hundred and ninety patients met both Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for borderline personality disorder and 72 met DSM-III-R criteria for at least one non-borderline axis II disorder (and neither criteria set for borderline personality disorder). Of these 72 comparison subjects, 58 (80.6%) met criteria for only one axis I disorder. Of the 14 (19.4%) who met criteria for two or more disorders, the primary disorder was determined by the severity of psychopathology reported. All told, the following primary axis II diagnoses were found: antisocial personality disorder (N=10, 13.9%), narcissistic personality disorder (N=3, 4.2%), paranoid personality disorder (N=3, 4.2%), avoidant personality disorder (N=8, 11.1%), dependent personality disorder (N=7, 9.7%), self-defeating personality disorder (N=2, 2.8%), and passive-aggressive personality disorder (N=1, 1.4%). Another 38 (52.8%) met criteria for personality disorder not otherwise specified (which was operationally defined in the Diagnostic Interview for DSM-III-R Personality Disorders as meeting all but one of the required number of criteria for at least two of the 13 axis II disorders described in DSM-III-R).
Baseline demographic data has been presented before (7). Briefly, 77.1% (N=279) of the subjects were female and 87% (N=315) were white. The average age of the subjects was 27 years (SD=6.3), the mean socioeconomic status was 3.3 (SD=1.5) (where 1=highest and 5=lowest) (16), and their mean GAF score was 39.8 (SD=7.8) (indicating major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood).
In terms of continuing participation, 87.5% (N=231/264) of surviving borderline patients (13 died by suicide and 13 died of other causes) were reinterviewed at all eight follow-up waves. A similar rate of participation was found for axis II comparison subjects, with 82.9% (N=58/70) of surviving patients in this study group (one died by suicide and one died of other causes) being reassessed at all eight follow-up waves.
Table 1 details time-to-attainment of remission from borderline personality disorder or another personality disorder lasting two, four, six, or eight years. As can be seen, estimated rates of remission were very high for both groups. By the time of the 16-year follow-up, the cumulative rates of remission for borderline patients ranged from 99% with a two-year remission to 78% with an eight-year remission. The corresponding rates for those with another personality disorder ranged from 99% to 97%. However, it is also clear that borderline patients remitted at a significantly slower pace than axis II comparison subjects. For each length of remission, about 30% of borderline patients achieved remission at the first possible time period, while the comparable figure for axis II comparison subjects was about 85%.
Table 1
Table 1
Cumulative Rates of Remission for Borderline Patients and Axis II Comparison Subjects Over 16 Years of Prospective Follow-up
Table 2 details time-to-recurrence of borderline personality disorder or another personality disorder after first achieving remission from that disorder. As can be seen, by the time of the 16-year follow-up, cumulative rates of recurrence for borderline patients ranged from 36% after a two-year remission to 10% after an eight-year remission. The comparable figures for axis II comparison subjects ranged from 7% to 4%. Borderline patients also experienced a recurrence significantly more rapidly than axis II comparison subjects experienced a recurrence after a two- to six-year remission.
Table 2
Table 2
Cumulative Rates of Recurrence for Borderline Patients and Axis II Comparison Subjects Over 16 Years of Prospective Follow-up
Table 3 details time-to-recovery from borderline personality disorder or another personality disorder, which as noted before, involves concurrent symptomatic remission as well as good social and vocational functioning. By the time of the 16-year follow-up, cumulative rates of recovery for borderline patients ranged from 60% for recoveries lasting two years to 40% for recoveries lasting eight years. In terms of axis II comparison subjects, cumulative rates of recovery ranged from 85% for recoveries lasting two years to 75% for recoveries lasting eight years. In addition, recoveries occurred significantly more slowly for borderline patients than axis II comparison subjects. For each length of recovery, about 10% of borderline patients achieved recovery at the first possible time period, while the comparable figure for axis II comparison subjects was about 40%.
Table 3
Table 3
Cumulative Rates of Recovery for Borderline Patients and Axis II Comparison Subjects Over 16 Years of Prospective Follow-up
Table 4 details time-to-loss of recovery for those in both study groups. For borderline patients, these losses ranged from a high of 44% after a recovery lasting two years to a low of 20% for a recovery lasting eight years. For axis II comparison groups, these losses ranged from a high of 28% after a recovery lasting two years to a low of 9% for a recovery lasting eight years. These between-group differences, while substantial, were not statistically significant.
Table 4
Table 4
Cumulative Rates of Loss of Recovery for Borderline Patients and Axis II Comparison Subjects Over 16 Years of Prospective Follow-up
Figure 1 graphically details the major points in these complex findings: remissions vs. recoveries and their loss; two-year vs. eight-year outcomes; borderline vs. comparison subjects. Figure 2 details time-to-remissions and recoveries lasting at least two years for those in both study groups.
Figure 1
Figure 1
Cumulative Rates of Remissions and Recoveries Lasting at Least Two Years or Eight Years and Their Subsequent Loss After 16 Years of Prospective Follow-up
Figure 2
Figure 2
Time-to-Remissions and Recoveries Lasting at Least Two Years for Patients with Borderline Personality Disorder and Axis II Comparison Subjects
Five main findings have emerged from this study. The first is that remissions lasting two to eight years are extremely common for borderline patients (and axis II comparison subjects). In fact, cumulative rates at 16-year follow-up for borderline patients ranged from a high of 99% for a two-year remission to 78% for an eight-year remission. These results are consistent with and extend our findings pertaining to the first 10 years of prospective follow-up in this study where we found that 93% of borderline patients had achieved a remission lasting two years (5). However, the results of the current study found that remissions, regardless of length, occurred significantly more rapidly for axis II comparison subjects than for borderline patients. This finding may reflect the greater severity of borderline psychopathology than the axis II psychopathology found in the other personality disorder group. Our findings pertaining to a two-year remission are also consistent with the follow-back findings of Paris (2) and the follow-along findings of the Collaborative Longitudinal Personality Disorders Study (6).
The second main finding is that recurrences of borderline personality disorder were relatively rare, ranging from 36% after a two-year remission to 10% after an eight-year remission. Axis II comparison subjects reported even lower rates of recurrence, ranging from 7% after a two-year remission to 4% after an eight-year remission. These results are consistent with and extend our findings pertaining to the first 10 years of prospective follow-up in this study where we found that 30% of borderline patients had a recurrence of borderline personality disorder after a two-year long remission (5). However, the results of the current study found that recurrences occurred significantly more slowly for axis II comparison subjects than for borderline patients. This finding is not surprising given the relative severity of borderline psychopathology. However, the opposite pattern was found in the Collaborative Longitudinal Personality Disorders Study where those with another personality disorder (who had as their primary axis II diagnosis either avoidant or obsessive-compulsive personality disorder) had higher rates of recurrence than those with borderline personality disorder (25% vs. 11%). This difference may be due to the substantially lower rates of retention in the Collaborative Longitudinal Personality Disorders Study after 10 years of prospective follow-up than in the McLean Study of Adult Development after 16 years of prospective follow-up (surviving borderline patients: 66% vs. 88%; surviving patients with another personality disorder: 69% vs. 83%). It may also be due to the fact that 13% of the other personality disorder group in the Collaborative Longitudinal Personality Disorders Study had a secondary diagnosis of borderline personality disorder at the time of study entry (17).
The third main finding is that recovery from borderline personality disorder occurred at a lower rate and more slowly than recovery from another personality disorder. In terms of recoveries lasting two years, 60% of borderline patients and 85% of axis II comparison subjects attained this important outcome. In terms of recoveries lasting eight years, these rates dropped to 40% and 75% respectively. It is not surprising that axis II comparison subjects achieved this outcome more rapidly and at a higher overall rate regardless of the length of recovery than those in the borderline group. This is so because previous research by our group has found that borderline patients have far more difficulty functioning consistently and competently in the vocational arena than axis II comparison subjects (18). We have also found that borderline patients are significantly more likely to support themselves through federal disability benefits than axis II comparison subjects (19). And yet these between-group differences are striking and represent a new finding.
The fourth main finding is that the loss of recovery was substantially but not significantly more common for borderline patients than axis II comparison subjects, in part due to the relatively small number of events in each group. Rates of loss of recovery after a two-year recovery were 44% for borderline patients and 28% for axis II comparison subjects. Rates of loss of recovery after an eight-year recovery were 20% and 9% respectively. These results too, which are new, probably reflect the unstable vocational performance of borderline patients relative to those with other forms of axis II psychopathology (18).
The fifth main finding is that recoveries occurred at lower rates than remissions for those in both study groups. Only 60% of borderline patients achieved a recovery lasting two years as opposed to 99% of borderline patients achieving a two-year remission. This discrepancy was smaller for those with another personality disorder as 99% had a two-year remission during the course of 16 years of prospective follow-up and 85% attained a two-year recovery involving symptomatic remission of their primary axis II diagnosis and good concurrent social and vocational functioning. In terms of remissions and recoveries lasting eight years, comparable figures for those in the borderline group were 78% remitted vs. 40% recovered. In the other personality disorder group, these figures were 97% remitted and 75% recovered. Clearly those in the other personality disorder group were more likely to both remit and recover, perhaps due to the lower level of severity of their axis II psychopathology or perhaps due to their greater capacity to perform vocationally or the confluence of the two.
Taken together, the results pertaining to high rates of remission of 2–8 years in length represent very good news for borderline patients, their families, and the mental health professionals treating them. The same can be said of the relatively low rates of recurrence following these lengthy remissions. Given these findings pertaining to symptomatic outcome, it seems fair to suggest that borderline personality disorder has a better symptomatic outcome than other major mental illnesses with which it is frequently compared, such as major depression (20,21) or bipolar I disorder (22,23).
However, our results pertaining to recovery are more sobering, particularly when compared with the rates of recovery attained by axis II comparison subjects. While 50% of borderline patients attained a two-year recovery after 10 years of prospective follow-up (5), only 60% attained this outcome after an additional six years of prospective follow-up. And this 60% compares unfavorably to the 85% of axis II comparison subjects who attained this outcome by the time of the 16-year follow-up period. Perhaps even more sobering is the fact that only 40% of borderline patients but 75% of axis II comparison subjects attained a recovery that lasted eight years or more (or half the length of prospective follow-up).
Cumulative rates of longer remissions and recoveries and the recurrences and losses of recovery that follow them might be expected to be lower than those for less lengthy outcomes due to the shorter risk periods involved. However, when differences in risk periods are taken into account, our results suggest that it is relatively more difficult to achieve longer remissions and recoveries than shorter ones. And that the lower rates of recurrence and loss of recovery are not solely artifacts of shorter risk periods but represent stable changes in symptomatology and psychosocial functioning.
As noted above, we have previously found that vocational impairment is the main reason that borderline patients fail to attain and/or maintain recovery involving both symptomatic remission and good social and vocational functioning (18,19). The reasons for the vocational dysfunction that drives the difficulty borderline patients have attaining and maintaining recovery are unclear and may differ from patient to patient. Some of this difficulty may be due to residual symptoms of borderline personality disorder. This difficulty may also be due, at least in part, to concurrent axis I disorders. However, our experience suggests that some borderline patients may be more goal oriented and more competent than others. Or looked at another way, some patients may be more resilient than others.
We have previously suggested a rehabilitation model to deal with this impairment in functioning (5). Links (24) and Gunderson et al. (6) have also suggested this approach to dealing with the vocational dysfunction common among seriously ill borderline patients.
However, not all therapists, family members, or friends are supportive of efforts to help the borderline patient attain a solid adult adaptation in the vocational realm. Some may be concerned that the stress of trying to work may lead to an upsurge in suicidal urges or episodes of self-mutilation. Others may believe that a borderline patient should not attempt to work until most of his or her more serious symptoms are fully resolved. Yet others may be concerned about the patient's losing access to the almost unlimited psychiatric treatment provided by Medicare, which is typically provided to those receiving Social Security Disability benefits.
In the end, some borderline patients will attain a good vocational adjustment and overall recovery with minimal support from those to whom they are close. Yet others will be able to attain this adaptation with much support and personal struggle. And yet others simply cannot or will not work consistently and/or competently and thus, will not attain our multifaceted definition of recovery. They too will need support as they bear the shame and disappointment attendant on failing to achieve the life they had once dreamt of and planned.
Poor health-related outcomes join vocational impairment as areas where a more guarded prognosis has been found (25). In particular, we have found that obesity and obesity-related illnesses are both common among borderline patients (2527) and associated with poor vocational functioning (27). We have also found that chronic PTSD, lack of exercise, a family history of obesity, and aggressive polypharmacy are risk factors for obesity in borderline patients (26). Further investigation of the interconnection of these poor prognostic factors is warranted.
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 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 non-intensive outpatient treatment over time (28) and thus, the results may not generalize to untreated subjects.
Taken together, the results of this study suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder. They also suggest that sustained remissions and recoveries are substantially more difficult for borderline patients to attain and maintain than those with other forms of personality disorder.
Acknowledgments
Supported by NIMH grants MH47588 and MH62169.
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