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Prospective cohort study.
McLean Hospital, Massachusetts, USA; enrolment 1992–1995.
290 adult inpatients (18–35 years) with a diagnosis of borderline personality disorder (BPD) (DSM-III-R and Revised Diagnostic Interview for Borderlines (DIB-R)). Exclusions: non-English speaking; IQ<70; current or prior schizophrenia, schizoaffective disorder, bipolar I disorder, or an organic condition causing psychiatric symptoms.
Three semistructured interviews were administered to assess participants for borderline personality and other axis II disorders at baseline and at 2 year follow up intervals (DIB-R; Diagnostic Interview for DSM-III-R Personality Disorders). Random effects regression models were used to analyse prevalence of comorbid axis II disorders. Remission was defined as no longer meeting criteria for borderline personality disorder. Time-to-event modelling methods were used to calculate hazard ratios and 95% confidence intervals.
Presence of axis II disorders (DSM-III-R), time to remission.
Follow up period:
At 6 years, 202 people had experienced remission from severe BPD. The prevalence of dependent, avoidant, self-defeating, narcissistic, and histrionic personality disorders was significantly higher among people whose BPD had never remitted, compared with those who had experienced remission (see table⇓, no significant difference in other axis II disorders). The overall prevalence of axis II comorbidities declined over time. However, avoidant personality disorder increased in the never-remitted group. People without avoidant, dependent, or self-defeating personality disorders had a significantly earlier remission from BPD than people with these comorbidities (self-defeating: HR for remission 4.1, 95% CI 1.8 to 9.3; avoidant: HR 2.0, 95% CI 1.3 to 2.9; dependent: HR 3.5, 95% CI 2.2 to 5.7).
In people with severe BPD the prevalence of axis II comorbidities decreases with time, particularly in people in remission. The presence of self-defeating, avoidant and dependent personality disorders increases time to remission in people with BPD, suggesting that these axis II disorders may hinder recovery.
Axis II disorders were assessed using DSM-III-R criteria, which is likely to differ from DSM-IV classification of axis II disorders. As participants were recruited as very disturbed inpatients, the findings of this study may not apply to less severely disturbed people with BPD. The study did not clearly establish the temporal relationship between comorbidity and remission, therefore a causality cannot be imputed.
Traditionally, it has been thought that personality disorders remain stable over time. Although temporal stability is central to these diagnoses constructs, reviews of the available empirical data suggest that, overall, personality disorders demonstrate only moderate stability and they can improve at a slow pace.1 Previous studies with a follow up of 2 years had found that personality disorders can change in their severity or in their expression.2 The most important aspect of this prospective research is that it questions the irreversibility of borderline personality disorder (BPD). The major finding of this study is that BPD declines with time, although some of people with BPD will continue to have other axis II diagnoses. Comorbidity of avoidant, dependent and self-defeating personality disorders diminishes the probability of remission of BPD.
BPD is a complex and serious mental disorder that occurs in 1–2% of the general population. It is associated with serious impairment in psychosocial functioning. The results of the study have some important implications for clinical practice: (1) systematic evaluation of comorbid personality disorders seems relevant for prognosis; and (2) people with BPD should receive treatment over a long period of time. Such treatment should include psychotherapy and pharmacotherapy.3
More prospective studies with long term follow up must be done to assess which are the best treatments for these patients.
For correspondence: Dr Mary C Zanarini, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA;
Sources of funding: National Institute of Mental Health, USA.