The Lifetime Course of Borderline Personality Disorder

Similar documents
BPD In Adolescence: Early Detection and Intervention

Redefining personality disorders: Proposed revisions for DSM-5

Clinical experience suggests. Ten-Year Use of Mental Health Services by Patients With Borderline Personality Disorder and With Other Axis II Disorders

Personality traits predict current and future functioning comparably for individuals with major depressive and personality disorders

Prospective assessment of treatment use by patients with personality disorders

PUBLICATION LIST ORIGINAL PUBLICATIONS IN PEER REVIEWED JOURNALS

BroadcastMed Bipolar, Borderline, Both? Diagnostic/Formulation Issues in Mood and Personality Disorders

Predictors of 2-year outcome for patients with borderline personality disorder

Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study

Dialectical Behavior Therapy: An Effective Treatment for Individuals with Comorbid Borderline Personality and Eating Disorders?

Donald W. Black, MD. Professor, Program Director, and Vice Chair for Education

Abstract. Comprehensive Psychiatry 48 (2007)

Psychotherapy of borderline personality disorder

Borderline personality disorder is characterized

Longitudinal Effects of Personality Disorders on Psychosocial Functioning of Patients With Major Depressive Disorder

Recognition and Treatment of Borderline Personality Disorder in the College and University Counseling Setting

Diagnosis of personality disorders in adolescents: a study among psychologists

Personality disorders. Personality disorder defined: Characteristic areas of impairment: The contributions of Theodore Millon Ph.D.

NIH Public Access Author Manuscript Psychol Med. Author manuscript; available in PMC 2012 February 6.

Introduction. Personality and Mental Health (2018) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI /pmh.

Copyright American Psychological Association. Introduction

Personality Disorder in Primary Care. Dr Graham Ingram Consultant Psychiatrist

Treatment utilization by patients with personality disorders

Personality traits and mental health treatment utilization

For years, investigators have expressed concern about

Approach to the Patient with Borderline Personality Disorder in Primary Care

Borderline Personality Disorder (BPD); then consider the costs of doing nothing, or

Personality Disorders. Mark Kimsey, M.D. March 8, 2014

Early intervention for Borderline Personality Disorder in young people Dr Andrew Chanen

Clinical outcomes of a stepped care program for borderline personality disorder

MEDICAL POLICY EFFECTIVE DATE: 04/28/11 REVISED DATE: 04/26/12, 04/25/13, 04/24/14, 06/25/15, 06/22/16, 06/22/17

2) Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and an

SECTION 1. Children and Adolescents with Depressive Disorder: Summary of Findings. from the Literature and Clinical Consultation in Ontario

Longitudinal diagnostic efficiency of DSM-IV criteria for obsessive compulsive personality disorder: a 2-year prospective study

Descriptive and Longitudinal Observations on the Relationship of Borderline Personality Disorder and Bipolar Disorder. Leslie C. Morey, Ph.D.

ZEV GOLDBERG, PHD JEFF MARINKO-SHRIVERS, PHD. 16 th Annual NADD State of Ohio IDD/MI Conference September 24, 2018 NORTHCOAST BEHAVIORAL HEALTHCARE

Awareness of Borderline Personality Disorder

Two-year stability and change of schizotypal, borderline, avoidant and obsessive-compulsive personality disorders

Downloaded from umj.umsu.ac.ir at 9: on Wednesday July 25th 2018

Personality traits as prospective predictors of suicide attempts

The treatment of personality disorder: Where are we? Where do we go from here? Where do we want to end up?

Almost half a century ago, Kernberg published his

ORIGINAL ARTICLE. Ten-Year Course of Borderline Personality Disorder

Positive Childhood Experiences: Resilience and Recovery From Personality Disorder in Early Adulthood

Responding Effectively to BPD Challenges for the Service System. Katerina Volny Peter McKenzie

Personality disorder in Scotland:

Can my personality be a disorder?!

Borderline personality disorder was first distinguished

This webinar is presented by

9 - SCREENING MEASURES FOR PERSONALITY DISORDERS

Can my personality be a disorder?!

Inpatient Psychiatry: Are There Opportunities for Documentation Improvement?

Towards a Conceptual Framework of Recovery in Borderline Personality Disorder

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE. Personality Disorder: the clinical management of borderline personality disorder

Global Alliance for Prevention and Early Intervention for Borderline Personality Disorder: Past, present and future Carla Sharp, Ph.D.

The UCD community has made this article openly available. Please share how this access benefits you. Your story matters!

A Clinical Translation of the Research Article Titled Antisocial Behavioral Syndromes and. Additional Psychiatric Comorbidity in Posttraumatic Stress

General introduction

New Research in Depression and Anxiety

Adult ADHD for GPs. Maria Mazfari Associate Nurse Consultant Adult ADHD Tina Profitt Clinical Nurse Specialist Adult ADHD

Tony Charman: Longitudinal studies for autism research

Differential impairment as an indicator of sex bias in DSM-IV criteria for four personality disorders.

Wesleyan University. From the SelectedWorks of Charles A. Sanislow, Ph.D.

Borderline Personality Disorder A Clinical Guide

Do eating disorders co-occur with personality disorders? Comparison groups matter.

SUMMARY AND DISCUSSION

Kim L. Gratz Department of Psychiatry and Human Behavior University of Mississippi Medical Center (UMMC)

Understanding borderline personality disorder

Borderline Personality Symptomatology, Casual Sexual Relationships, and Promiscuity

This webinar is presented by

The Relationship between Personality Disorders and Quality of Life in Adolescent Outpatients

Seven-Year Course of Borderline Personality Disorder Features: Borderline Pathology Is as Unstable as Depression During Adolescence

The shift in nosology from the Diagnostic PROCEEDINGS FROM CHILDHOOD TO ADOLESCENCE: DIAGNOSIS AND COMORBIDITY ISSUES * Thomas J. Spencer, MD ABSTRACT

Diatheses and Stressors in Borderline Pathology of Childhood: The Role of Neuropsychological Risk and Trauma

Validity of DAS perfectionism and need for approval in relation to the five-factor model of personality

Characteristics of Borderline Personality Disorder Associated With Suicidal Behavior

Ten-Year Rank-Order Stability of Personality Traits and Disorders in a Clinical Sample

Interactions of Borderline Personality Disorder and Mood Disorders Over 10 Years

ali. com

Chapter 9 Borderline Personality and Mood Disorders: Risk Factors, Precursors, and Early Signs in Childhood and Youth

Personality Disorders

Long term predictive validity of diagnostic models for personality disorder: Integrating trait and disorder concepts

Comorbidity With Substance Abuse P a g e 1

Slide 1. Slide 2. Slide 3 Similar observations in all subsets of the disorder. Personality Disorders. General Symptoms. Chapter 9

Borderline personality disorder: what role for medication?

Obsessive-Compulsive Disorder Clinical Practice Guideline Summary for Primary Care

Avoidant personality disorder and social phobia: distinct enough to be separate disorders?

Borderline Personality Disorder and Addiction. What s in a name? DSM-IV TR Diagnostic Criteria. Erica Hoff, PhD Licensed Clinical Psychologist

TITLE: Group Therapy for Adults with Axis II Disorders: A Review of Clinical Effectiveness

Affective Disorders among Patients with Borderline Personality Disorder

Panic Disorder Prepared by Stephanie Gilbert Summary

Can my personality be a disorder?!

Training Clinicians to treat BPD A DBT training program for psychiatry residents. Beth S. Brodsky, Ph.D. NEA-BPD April 28, 2013

Borderline Personality Disorder: An Introduction

Factor Structure of Borderline Personality Disorder Symptomatology in Adolescents

FAMILY THERAPY OR FAMILY BASED INTERVENTION FOR CHILDREN AND ADOLESCENTS WHO SUFFER FROM PSYCHIATRIC DISORDERS

BORDERLINE PERSONALITY DISORDER: A LITTLE COMPASSION CAN GO A LONG WAY

Transcription:

CanJPsychiatry 2015;60(7):303 308 In Review The Lifetime Course of Borderline Personality Disorder Robert S Biskin, MDCM 1 1 Staff Psychiatrist, Institute of Community and Family Psychiatry, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec; Assistant Professor, Department of Psychiatry, McGill University, Montreal, Quebec. Correspondence: Institute of Community and Family Psychiatry, 4333 Côte-Ste-Catherine Road, Montreal, QC H3T 1E4; robert.biskin@mcgill.ca. Key Words: borderline personality disorder, long-term outcome, review, natural history Received and accepted March 2015. Borderline personality disorder (BPD) has historically been seen as a lifelong, highly disabling disorder. Research during the past 2 decades has challenged this assumption. This paper reviews the course of BPD throughout life, including childhood, adolescence, and adulthood. BPD can be accurately identified in adolescence, and the course of the disorder, in adolescence and adulthood, is generally similar, with reductions in symptoms over time. Functional recovery is less consistent, and further research on factors or treatments that may improve the long-term functional outcome of patients with BPD is warranted. W W W Le cours durant la vie du trouble de la personnalité limite Le trouble de la personnalité limite (TPL) a été considéré historiquement comme étant un trouble très incapacitant qui dure toute la vie. La recherche des 20 dernières années a remis en question cette hypothèse. Cet article examine le cours du TPL tout au long de la vie, y compris l enfance, l adolescence, et l âge adulte. Le TPL peut être identifié avec précision à l adolescence, et le cours du trouble, à l adolescence et à l âge adulte, est généralement semblable, et s accompagne d une réduction des symptômes avec le temps. Le rétablissement fonctionnel est moins constant, et il faut plus de recherches sur les facteurs ou les traitements qui peuvent améliorer le résultat fonctionnel à long terme des patients souffrant du TPL. Patients with BPD are very frequently seen in all types of clinical settings. They account for 10% of outpatients, 1 20% of inpatients, 2 and 6% of patients presenting to family medicine, 3 despite a community prevalence of 1% to 2%. 4 In the community, there is an equal gender ratio, despite women being seen 3 to 4 times more frequently in clinical settings. 4 If they are not seen as part of a long-term followup or a treatment program, they are typically seen when in crisis. 5 This has given many the impression that patients with BPD are always in crisis and never recover from their illness, leading to this group of patients being highly stigmatized in the mental health care system. 6,7 Patients with BPD do suffer intensely, but their prognosis is often better than expected and the outcomes are further improved with appropriate treatment. Like all PDs, BPD requires that patients have difficulties that are pervasive, inflexible, impairing, and outside the norm for their cultural background. DSM-5 also indicates that the pattern of behaviour begins in adolescence or early adulthood, if not earlier. DSM-5, like DSM-IV, permits diagnosing a PD (other than antisocial PD) in someone under 18 years of age if the symptoms are pervasive, persistent, and unlikely to be limited to a particular developmental stage or another mental disorder, 8, p 647 as long as symptoms have been present for 1 year or longer. 8 This review will describe the longitudinal course of BPD in all age groups, with a focus on the functional and symptomatic outcomes of these patients. Methods A MEDLINE search from 1946 until 2015 was conducted using the terms borderline personality disorder and course. A total of 268 references were obtained and these were reviewed for relevance. In addition, references specifically relating to the 2 largest longitudinal studies were reviewed. Early Onset Zanarini et al 9 have demonstrated that patients with BPD begin their first treatment, typically individual psychotherapy, at the age of 18, although symptoms are likely to start earlier. Her team has also demonstrated that over 30% of patients with BPD began self-harming when they were 12 years of age or less, with another 30% initiating self-harm between the ages of 13 and 17. 10 As previously mentioned, DSM-5 permits the diagnosis of BPD in patients younger than 18 if symptoms persist for at least 1 year. Symptoms of BPD usually start prior to adulthood and the diagnosis can be made reliably. www.thecjp.ca The Canadian Journal of Psychiatry, Vol 60, No 7, July 2015 W 303

In Review There have been many different precursor syndromes proposed for the diagnosis of BPD, 11 but none have examined how often these patients will meet criteria in adulthood. Paris and colleagues (see Paris et al 12 and Guzder et al 13 ) examined a syndrome called borderline pathology of childhood, which combines symptoms in affective, impulsive, and cognitive domains, modelling the criteria and diagnostic measure after the Diagnostic Interview for Borderlines, a semi-structured interview that identifies a more homogenous population than the DSM-5 criteria and is one of the most reliable diagnostic measures for BPD in all age groups. 14,15 These authors found that children from ages 7 to 12 who meet criteria for borderline pathology of childhood were more likely than a clinical comparison group to have experienced abuse and neglect, as well as to have neuropsychological findings suggesting executive dysfunction, 12,13 similar to what is found in adults with BPD. 16,17 When this group was reassessed 5 years later at a mean age of 15 years old, only a handful of patients met criteria for BPD, although the group that met criteria for borderline personality of childhood did have poorer functioning as adolescents. 18 Another study 19 looked at a large community sample of high-risk girls between the ages of 6 and 12. This study reported several important findings, including that both parent and teacher ratings of characteristic features of BPD, such as lack of control and aggression, are quite stable during 6 years of follow-up. These results suggest that, while BPD symptoms may begin in childhood in some patients, it is not yet possible to identify a precursor syndrome specific to BPD. Thus there is an absence of evidence regarding the course and outcomes of patients who do meet the full criteria for BPD in childhood. Adolescence While BPD in childhood is a relatively understudied topic, there is growing evidence that BPD can be reliably and validly diagnosed in adolescence. The course of adolescentonset BPD is similar to what is seen in adult populations. 20 There are an increasing number of studies that examine the outcomes of patients diagnosed with BPD in adolescence. Abbreviations BPD DBT CLPS DSM MDD MSAD PD SUD borderline PD dialectical behaviour therapy Collaborative Longitudinal Personality Disorders Study Diagnostic and Statistical Manual of Mental Disorders major depressive disorder McLean Study of Adult Development personality disorder substance use disorder 304 W La Revue canadienne de psychiatrie, vol 60, no 7, juillet 2015 Clinical Implications BPD begins in adolescence. BPD is not necessarily a lifelong disorder. Many patients retain residual symptoms later in life. Limitations Residual symptoms in BPD may not be predictable. Little research has been conducted on the management of these symptoms in recovered patients with BPD. In general, the course of BPD during adolescence is not very stable. In particular, a prospective study 20 of a clinical population between the ages of 15 and 18 found that only 40% of patients with BPD met criteria at 2-year follow-up. However, this sample only included a smaller number of adolescents with BPD, as this study looked at the course of all PDs. A community study of self-reported symptoms in adolescent twins also found a decrease in rates of BPD diagnosis from 14 to 24 years of age, with significant reductions in symptoms at each 2- to 3-year interval throughout the 10-year follow-up. 21 A 2-year follow-up of adolescent inpatients also found a change of diagnosis, with an over 50% reduction in the number of patients with BPD at follow-up. 22 However, a large longitudinal community study of adolescents with 2- and 8-year follow-up 23 25 found that BPD symptoms tended to persist, even when formal diagnostic criteria were no longer met. When a sample of adolescents previously diagnosed with BPD were followed up about 4 years later, 65% remitted from the diagnosis, consistent with other studies. 26 Another research group attempted to identify risk factors for the development of BPD in a community sample of adolescents, and found that maternal child discord, maternal BPD, paternal SUD, as well as depression, SUD, and suicidality in the adolescent, predict later development of BPD symptoms. 27 These risks may moderate the improvement of patients during this phase of development. Adulthood The course of BPD in adults has been a focus of research during the past 2 decades, with several longitudinal studies providing insights into its course. The 2 most important prospective studies are the MSAD and the CLPS. The MSAD, which is still ongoing after 20 years, is a prospective, longitudinal study that has been following a group of 290 patients who were initially hospitalized at McLean Hospital with a diagnosis of BPD and a comparison group of 72 patients initially hospitalized with other PD diagnoses. Reassessments occur every 2 years and include various measures to assess symptomatology, functioning, and comorbid psychiatric and medical conditions. 28 The CLPS recruited 668 patients from several different sites, mostly as outpatients, who met criteria for either BPD, avoidant PD, obsessive compulsive PD, schizotypal PD, or MDD without a comorbid PD. These patients were reassessed www.larcp.ca

The Lifetime Course of Borderline Personality Disorder 6 months after baseline and then annually for 10 years. Measures also focused on symptomatology, comorbidity, and functioning, but also included several assessments of dimensional personality traits. 29 Both studies found that most patients with BPD improve with time. The CLPS provides evidence that, even when followed up 2 years after the initial assessment, about onequarter of patients experience a remission of the diagnosis (defined here as meeting less than 2 symptoms for a period of 2 months or longer) during the prior 2 years. During a 10- year period of follow-up, 91% achieve at least a 2-month remission, with 85% achieving remission for 12 months or longer. 30 The MSAD has found similar results extended out to 16 years using a slightly different definition of remission (no longer meeting diagnostic criteria for a period of 2 years or longer) and found that by 16 years, 99% of patients have at least a 2-year period of remission and 78% have a remission lasting 8 years. 31 Both of these studies also demonstrated that BPD is slower to remit than other PDs and MDD. Finally, 1 study followed patients after 27 years and found that 92% of them no longer met criteria for BPD. 32 However, rates of recurrence were not quite consistent between studies. In the CLPS, recurrence rates for patients with BPD were 11% at 10-year follow-up in those who had achieved at least a 12-month remission. This was significantly lower than for the other PDs and also significantly lower than the recurrence rate for patients with MDD. 30 The MSAD found that recurrence rates decreased the longer the remission lasted; 36% of patients experienced a recurrence if their remission lasted only 2 years, but this declined to 10% if their remission lasted 8 years. In general, the BPD group was faster to remit than the comparison group of patients with other PDs. 31 Taken together, these results suggest that patients with BPD are able to achieve remission of symptoms, and that the longer the remission lasts, the lower the risk of relapse. When the course of individual symptoms of BPD are examined, studies have generally demonstrated an overall decrease in all symptoms, but with symptoms relating to impulsivity and behavioural manifestations of BPD remitting at a quicker rate than internal, primarily affective experiences. 30,33 In general, behavioural symptoms of PDs are less stable than the personality traits associated with BPD over time. 34 Despite early reductions in symptoms of self-harm and suicidality, the risk of completed suicide remains. After 27 years of followup, about 10% of patients completed suicide, typically when patients were in their 30s and after multiple failed treatments. 32 The MSAD found a suicide rate of about 5% and an identical rate of death by all other causes. 31 In this sample, several factors were associated longitudinally with suicide attempts, including comorbid MDD, SUD, posttraumatic stress disorder, family history of suicide, and some specific symptoms of BPD. 35 However, based on previous research in retrospective studies, the rate of suicide in BPD can be expected to fall between 8% and 10%. 36,37 Comorbid psychiatric disorders are extremely common in patients with BPD. Mood disorders, particularly MDD, SUDs, anxiety disorders, and eating disorders are more frequently seen in patients with BPD, compared with patients with other PDs. Even after 6 years of follow-up, over 60% of BPD patients met criteria for a mood disorder and a similar rate for an anxiety disorder. 38 Presence of a BPD diagnosis is also associated with longer duration to recovery from some psychiatric illness, such as MDD. 39 Comorbid PDs are also more frequent in patients with BPD, and comorbid avoidant, dependent, and self-defeating PDs were associated with lower rates of remission from BPD. 40 Comorbid medical conditions are also significant problems for patients with BPD, including irritable bowel syndrome, 41 osteoarthritis, diabetes, obesity, and others. 42 Patients with BPD also experience more frequent and more intense pain 43 with increased use of opiate medications. 44 In general, rates of psychiatric and medical treatment use, including psychiatric medications, are much higher in patients with BPD and, although there is decline during the first 8 years of follow-up, treatment use remains relatively elevated and unchanged after that. 42,45,46 It is also notable that overall rates of mortality in BPD are elevated, compared with the general population. 32 Treatment Implications Understanding the course of BPD can have a significant impact on the clinical management of patients with the disorder. One of the first issues is accurately diagnosing the disorder. As previously discussed, BPD can often be identified in adolescents and young adults, and it is at this age that clinicians should start to look for symptoms of the disorder. The course of the disorder appears unstable during adolescence, yet the long-term course for most patients is essentially identical to what is seen in adults. As evidencebased treatments are available although evidence in youth is not as robust as it is in adults 47 patients should be directed to these psychotherapies as early as possible. There is no rationale to wait to provide diagnosis and treatment, and many of the arguments for waiting (based on the assumption that symptoms are transient) are not based on evidence. 48 Finally, providing an accurate diagnosis and providing information on the generally positive outcomes for BPD can instill hope in patients who, all too often, feel completely hopeless. 49 Evidence suggests that even a single session of psychoeducation about the diagnosis can be beneficial. 50 One of the all-too-frequent reasons to avoid the diagnosis of BPD in all age groups is the fear of stigmatization. BPD is known to be highly stigmatized in mental health settings, 6,7,51,52 particularly in youth mental health, and part of the reason for the stigma is that BPD is seen as a lifelong disorder that is untreatable. Actually, patients with BPD can be cautiously optimistic about their prognosis, and many treatments exist that can profoundly improve their lives. Much of the stigma occurs when clinicians encounter these patients in crisis settings, such as the emergency www.thecjp.ca The Canadian Journal of Psychiatry, Vol 60, No 7, July 2015 W 305

In Review department, crisis clinics, and general psychiatric inpatient wards. As these are not the settings in which treatment occurs, clinicians develop a biased perspective on these patients. Few clinicians will have the opportunity to see these patients improve over time in specialized treatment clinics; nonetheless, these patients improve and are treatable. Awareness of the course of BPD is one effective way of reducing stigma against the diagnosis. Although the course of BPD is generally positive, some patients do experience relapses over time. Most of the specialized treatments for BPD are time-limited and generally of 1 to 3 years duration. This makes them expensive, and some experts suggest that a better model of care for patients with BPD would be intermittent psychotherapy. 53 Intermittent treatment may allow patients to address different problems at different points in their lives. For example, DBT focuses primarily on self-harm and suicidality, 54 which tend to be problems early on in the lives of patients with BPD. As these symptoms remit with time, patients who are older may want to deal with problems relating to emptiness and fear of abandonment, which are not directly addressed by DBT, and are symptoms that are slower to remit. 33 An intermittent psychotherapy model would allow patients to focus on specific problems at specific times in their lives, using the therapeutic approach that has the best evidence for that problem. A related issue is the poor long-term functional status of patients with BPD. Zanarini et al 31 demonstrated that recovery is significantly less likely in patients with BPD than in an Axis II comparison group. Slightly more than onehalf the patients with BPD achieved recovery, which was defined as remission from symptoms as well as good, fulltime vocational or educational functioning and at least one stable and supportive relationship with a friend or partner. Patients with BPD were also quite likely to rapidly lose their recovery. Several factors were identified as predictors to recovery, including not being hospitalized (prior to the index hospitalization), higher IQ, prior good vocational functioning, absence of a cluster C comorbidity, and the trait measures of high extraversion and high agreeableness. 55 Recovery was also associated with both marriage and being a parent, although often at an older age than nonrecovered patients. 56 Another longitudinal study demonstrated that the Global Assessment of Functioning scores were lower in the BPD group and significantly fewer of these patients achieved levels that represent good functioning 30 and were also more likely to receive social assistance. As functional recovery is so difficult for patients with BPD to attain and maintain, this becomes an important long-term goal for intervention. Currently, the only long-term study to directly assess vocational or educational functioning indicates that mentalization-based treatment, provided in an 18-month partial hospitalization setting, is associated with a greater chance of being employed or in school up to 8 years later. 57 Other studies have also demonstrated improved social and global functioning, but these were 306 W La Revue canadienne de psychiatrie, vol 60, no 7, juillet 2015 not primary outcomes and were not significantly different between the different treatments; also, duration of followup was too short. 58,59 Thus there is evidence that, while treatment is likely to lead to improvements in functional recovery, there is a notable absence of studies that focus on this as a primary outcome. Consideration should be given to providing patients with BPD as much support in attaining functional recovery as possible. This may include psychosocial programs aimed at returning to work, and evaluation and involvement from occupational therapists, vocational counsellors, or other specialists who can help patients develop the skills necessary for any sort of work. Future Areas of Focus for Research Research on the longitudinal course of BPD has progressed dramatically during the past 2 decades. Despite this, there are several areas in which further progress is desired. The first is early identification of people at high risk of development of BPD. Large-scale studies may be helpful in identifying constellations of risk factors, symptoms, and traits that predict BPD. One study, the Pittsburgh Girls Study, 60 is a longitudinal community study of over 2000 girls recruited at between 5 and 8 years of age. The focus of this project has been on the development of conduct disorder and MDD, although further research on the development of BPD is expected. If children can be identified with early symptomatology, or even in a highrisk setting, new treatments that incorporate family or community interventions could be developed. At the other end of the life course, there is very little research on BPD in older populations. What research does exist demonstrates that, as mentioned previously, impulsive symptoms declined early in life, but symptoms related to negative affectivity, such as emptiness, may remain or worsen, and are associated with more social impairment. 61,62 In general, changes in personality traits tend to decrease with age, although one sees an overall decrease in neuroticism, extraversion, and openness, as well as an increase in agreeableness and conscientiousness. 63 As patients with BPD tend to experience many physical health problems, and as these are associated with continuation of illness, 42 awareness of BPD in later life remains important. It is hoped that the ongoing longitudinal studies of BPD will be able to provide some insight into the major challenges patients with BPD experience as they age. Finally, the problem with relatively low and poorly sustained functional recovery in BPD remains an area of further research. The long-term follow-up of patients who have completed specialized psychotherapies will be useful in examining what can be done to improve the quality of life in patients with BPD. Conclusions Research during the past 2 decades has clearly demonstrated that BPD has a positive trajectory over time. Although it is a disorder associated with many psychiatric and medical www.larcp.ca

The Lifetime Course of Borderline Personality Disorder comorbidities, many of the most troubling symptoms remit during the first few years. Unfortunately, several of the underlying personality traits remain for longer periods, and these are the elements of the disorder that may not be fully addressed by current treatments. Many of the specialized psychotherapies help patients with BPD, but long-term functional recovery is difficult. One potential solution to this problem is in early identification of patients with BPD. Early intervention may allow these patients to resume a healthier trajectory early on in life and to attain the social and vocational functioning that is often challenging for somewhat older patients. The lives of patients with BPD has improved significantly with specialized treatments, and further refining these treatments for a younger population may lead to greater changes in the long-term course of BPD. Acknowledgements Dr Biskin has previously received an honorarium from Elsevier for publications related to borderline personality disorder. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors. References 1. Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162(10):1911 1918. 2. Zimmerman M, Chelminski I, Young D. The frequency of personality disorders in psychiatric patients. Psychiatr Clin North Am. 2008;31(3):405 420. 3. Gross R, Olfson M, Gameroff M, et al. Borderline personality disorder in primary care. Arch Intern Med. 2002;162(1):53 60. 4. Paris J. Estimating the prevalence of personality disorders in the community. J Pers Disord. 2010;24(4):405 411. 5. Zaheer J, Links PS, Liu E. Assessment and emergency management of suicidality in personality disorders. Psychiatr Clin North Am. 2008;31(3):527 543, viii ix. 6. Kealy D, Ogrodniczuk JS. Marginalization of borderline personality disorder. J Psychiatr Pract. 2010;16(3):145 154. 7. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harv Rev Psychiatry. 2006;14(5):249 256. 8. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): APA; 2013. 9. Zanarini MC, Frankenburg FR, Khera GS, et al. Treatment histories of borderline inpatients. Compr Psychiatry. 2001;42:144 150. 10. Zanarini MC, Frankenburg FR, Ridolfi ME, et al. Reported childhood onset of self-mutilation among borderline patients. J Pers Disord. 2006;20(1):9 15. 11. Zelkowitz P, Guzder J, Paris J, et al. Borderline pathology of childhood: implications of early Axis II diagnoses. Can Child Adolesc Psychiatry Rev. 2004;13(3):58 61. 12. Paris J, Zelkowitz P, Guzder J, et al. Neuropsychological factors associated with borderline pathology in children. J Am Acad Child Adolesc Psychiatry. 1999;38(6):770 774. 13. Guzder J, Paris J, Zelkowitz P, et al. Psychological risk factors for borderline pathology in school-age children. J Am Acad Child Adolesc Psychiatry. 1999;38(2):206 212. 14. Zanarini MC, Gunderson JG, Frankenburg FR, et al. The face validity of the DSM-III and DSM-III-R criteria sets for borderline personality disorder. Am J Psychiatry. 1991;148(7):870 874. 15. Zanarini MC, Gunderson JG, Frankenburg FR, et al. The Revised Diagnostic Interview for Borderlines: discriminating BPD from other Axis II disorders. J Pers Disord. 1989;3(1):10 18. 16. Battle CL, Shea MT, Johnson DM, et al. Childhood maltreatment associated with adult personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study. J Pers Disord. 2004;18(2):193 211. 17. Ruocco AC. The neuropsychology of borderline personality disorder: a meta-analysis and review. Psychiatry Res. 2005;137(3):191 202. 18. Zelkowitz P, Paris J, Guzder J, et al. A five-year follow-up of patients with borderline pathology of childhood. J Pers Disord. 2007;21(6):664 674. 19. Stepp SD, Pilkonis PA, Hipwell AE, et al. Stability of borderline personality disorder features in girls. J Pers Disord. 2010;24(4):460 472. 20. Chanen AM, Jackson HJ, McGorry PD, et al. Two-year stability of personality disorder in older adolescent outpatients. J Pers Disord. 2004;18(6):526 541. 21. Bornovalova MA, Hicks BM, Iacono WG, et al. Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: a longitudinal twin study. Dev Psychopathol. 2009;21(4):1335 1353. 22. Mattanah JJF, Becker DF, Levy KN, et al. Diagnostic stability in adolescents followed up 2 years after hospitalization. Am J Psychiatry. 1995;152(6):889 894. 23. Bernstein DP, Cohen P, Velez CN, et al. Prevalence and stability of the DSM-III-R personality disorders in a community-based survey of adolescents. Am J Psychiatry. 1993;150(8):1237 1243. 24. Crawford TN, Cohen P, Brook JS. Dramatic-erratic personality disorder symptoms: II. Developmental pathways from early adolescence to adulthood. J Pers Disord. 2001;15(4):336 350. 25. Crawford TN, Cohen P, Brook JS. Dramatic-erratic personality disorder symptoms: I. Continuity from early adolescence into adulthood. J Pers Disord. 2001;15(4):319 335. 26. Biskin RS, Paris J, Renaud J, et al. Outcomes in women diagnosed with borderline personality disorder in adolescence. J Can Acad Child Adolesc Psychiatry. 2011;20(3):168 174. 27. Stepp SD, Olino TM, Klein DN, et al. Unique influences of adolescent antecedents on adult borderline personality disorder features. Personal Disord. 2013;4(3):223 239. 28. Zanarini MC, Frankenburg FR, Hennen J, et al. The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up. J Pers Disord. 2005;19(5):505 523. 29. Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Pers Disord. 2005;19(5):487 504. 30. Gunderson JG, Stout RL, McGlashan TH, et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Arch Gen Psychiatry. 2011;68(8):827 837. 31. Zanarini MC, Frankenburg FR, Reich DB, et al. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry. 2012;169(5):476 483. 32. Paris J, Zweig-Frank H. A 27-year follow-up of patients with borderline personality disorder. Compr Psychiatry. 2001;42(6):482 487. 33. Zanarini MC, Frankenburg FR, Reich DB, et al. The subsyndromal phenomenology of borderline personality disorder: a 10-year follow-up study. Am J Psychiatry. 2007;164(6):929 935. 34. Hopwood CJ, Morey LC, Donnellan MB, et al. Ten-year rank-order stability of personality traits and disorders in a clinical sample. J Pers. 2013;81(3):335 344. 35. Wedig MM, Silverman MH, Frankenburg FR, et al. Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychol Med. 2012;42(11):2395 2404. 36. Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatry. 2006;163(1):20 26. 37. Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53(6):738 742. 38. Zanarini MC, Frankenburg FR, Hennen J, et al. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry. 2004;161(11):2108 2114. 39. Grilo CM, Sanislow CA, Shea MT, et al. Two-year prospective naturalistic study of remission from major depressive disorder as a www.thecjp.ca The Canadian Journal of Psychiatry, Vol 60, No 7, July 2015 W 307

In Review function of personality disorder comorbidity. J Consult Clin Psychol. 2005;73(1):78 85. 40. Zanarini MC, Frankenburg FR, Vujanovic AA, et al. Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission. Acta Psychiatr Scand. 2004;110(6):416 420. 41. Niesten IJ, Karan E, Frankenburg FR, et al. Prevalence and risk factors for irritable bowel syndrome in recovered and non-recovered borderline patients over 10 years of prospective follow-up. Personal Ment Health. 2014;8(1):14 23. 42. Keuroghlian AS, Frankenburg FR, Zanarini MC. The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. J Psychiatr Res. 2013;47(10):1499 1506. 43. Biskin RS, Frankenburg FR, Fitzmaurice GM, et al. Pain in patients with borderline personality disorder. Personal Ment Health. 2014;8(3):218 227. 44. Frankenburg FR, Fitzmaurice GM, Zanarini MC. The use of prescription opioid medication by patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study. J Clin Psychiatry. 2014;75(4):357 361. 45. Zanarini MC, Frankenburg FR, Reich DB, et al. Treatment rates for patients with borderline personality disorder and other personality disorders: a 16-year study. Psychiatr Serv. 2015;66(1):15 20. 46. Zanarini MC, Frankenburg FR, Bradford Reich D, et al. Rates of psychotropic medication use reported by borderline patients and Axis II comparison subjects over 16 years of prospective follow-up. J Clin Psychopharmacol. 2015;35(1):63 67. 47. Biskin RS. Treatment of borderline personality disorder in youth. J Can Acad Child Adolesc Psychiatry. 2013;22(3):230 234. 48. Kaess M, Brunner R, Chanen A. Borderline personality disorder in adolescence. Pediatrics. 2014;134(4):782 793. 49. Biskin RS, Paris J. Diagnosing borderline personality disorder. CMAJ. 2012;184(16):1789 1794. 50. Zanarini MC, Frankenburg FR. A preliminary, randomized trial of psychoeducation for women with borderline personality disorder. J Pers Disord. 2008;22(3):284 290. 51. Koehne K, Hamilton B, Sands N, et al. Working around a contested diagnosis: borderline personality disorder in adolescence. Health (London). 2013;17(1):37 56. 52. Miller AL, Muehlenkamp JJ, Jacobson CM. Fact or fiction: diagnosing borderline personality disorder in adolescents. Clin Psychol Rev. 2008;28(6):969 981. 53. Paris J. Intermittent psychotherapy: an alternative to continuous long-term treatment for patients with personality disorders. J Psychiatr Pract. 2007;13(3):153 158. 54. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York (NY): Guilford Press; 1993. p xvii, 558 p. 55. Zanarini MC, Frankenburg FR, Reich DB, et al. Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years. Acta Psychiatr Scand. 2014;130(3):205 213. 56. Zanarini MC, Frankenburg FR, Reich DB, et al. The course of marriage/sustained cohabitation and parenthood among borderline patients followed prospectively for 16 years. J Pers Disord. 2015;29(1):62 70. 57. Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165(5):631 638. 58. Clarkin JF, Levy KN, Lenzenweger MF, et al. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):922 928. 59. McMain SF, Links PS, Gnam WH, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1365 1374. Erratum in Am J Psychiatry. 2010;167(10):1283. 60. Keenan K, Hipwell A, Chung T, et al. The Pittsburgh Girls Studies: overview and initial findings. J Clin Child Adolesc Psychol. 2010;39(4):506 521. 61. Arens EA, Stopsack M, Spitzer C, et al. Borderline personality disorder in four different age groups: a cross-sectional study of community residents in Germany. J Pers Disord. 2013;27(2):196 207. 62. Morgan TA, Chelminski I, Young D, et al. Differences between older and younger adults with borderline personality disorder on clinical presentation and impairment. J Psychiatr Res. 2013;47(10):1507 1513. 63. Debast I, van Alphen SPJ, Rossi G, et al. Personality traits and personality disorders in late middle and old age: do they remain stable? A literature review. Clin Gerontol. 2014;37(3):253 271. 1956 to 2015 of Medical Publishing Excellence For 60 years, Canadian psychiatrists have turned to The Canadian Journal of Psychiatry for reliable research they can use in their clinical practices to improve patient care. d excellence en publication médicale Depuis 60 ans, les psychiatres canadiens consultent La Revue canadienne de psychiatrie pour des études fiables qu ils peuvent utiliser dans leurs pratiques cliniques afin d améliorer les soins des patients. Dr. F. Rhodes Chalke Editor, 1955 to 1971 308 W La Revue canadienne de psychiatrie, vol 60, no 7, juillet 2015 www.larcp.ca