Course of Borderline Personality Disorder

Although Borderline Personality Disorder (BPD) is usually diagnosed in young adulthood, indicators such as unstable affect or self-harming behaviour are often first observed during adolescence (Winograd, Cohen, & Chen, 2008).

BPD has long been regarded as a chronic, unrelenting disorder — a sentence to a life of misery. Unfortunately, this misconception has contributed to pessimism within the mental health field regarding treatment response. Recent research findings have done much to disconfirm this notion. It is now recognized that BPD has a less stable course than previously expected, with several features of the disorder diminishing over time (Gunderson, 2011; Leichsenring et al., 2011).

A long-term study of borderline personality disorder, conducted over 10 years (Zanarini, Frankenburg, Reich, et al., 2007), found that half of the 24 BPD symptoms assessed showed patterns of sharp decline over time and were reported at 10-year follow-up by less than 15% of the patients who reported them at baseline. The other 12 symptoms showed patterns of less dramatic decline over the 10-year period. Symptoms reflecting core areas of impulsivity (e.g., self-mutilation and suicide efforts) and active attempts to manage interpersonal difficulties (e.g., problems with being demanding/entitlement and serious treatment regressions) seemed to resolve the most quickly. In contrast, affective symptoms reflecting areas of chronic dysphoria (e.g., anger and loneliness/emptiness) and interpersonal symptoms reflecting abandonment and dependency issues (e.g., intolerance of aloneness and counter-dependency problems) seemed to be the most stable.

Another 10-year longitudinal study (Gunderson, Stout, McGlashan, et al., 2011) also found high rates of remission among patients with BPD. At ten years, 85% of patients no longer met any more than two diagnostic criteria for at least 12 months (defined as remission in the study). Only twelve percent of patients experienced relapse. Although remission of BPD was achieved more slowly in comparison to patients with major depression, the frequency of relapse was less than for patients without BPD (e.g. major depression). Such findings provide encouragement for those who suffer from BPD, their families, and mental health care providers. However, there is also cause for concern regarding the course of BPD. The rate of completed suicide among individuals with BPD is about 10% (Oldham, 2006). In other words, death by suicide will eliminate the possibility of recovery for about 1 in 10 persons with BPD. Longitudinal research also indicates a severe impairment in social functioning among BPD patients that is sustained over time, significantly more so than among patients with major depression or other personality disorders.

At present, little is known regarding the mechanisms of recovery and remission in BPD. Temperament may partially influence the gradual decline of symptoms (Zanarini et al., 2007). Situational changes, such as improved interpersonal relationships and reduced psychosocial stress, may also contribute to a reduction in symptom intensity (Gunderson et al., 2003). The development of several effective treatments for BPD has also helped to improve the prognosis of those affected with this disorder (See pages on Pharmacotherapy and Psychotherapy for BPD). It has been estimated that patients with personality disorders who receive psychotherapy will experience recovery up to seven times faster than the natural course of the illness (Perry, Banon, & Ianni, 1999).