Personality disorders involve long term, problematic behaviors that typically are first exhibited during adolescence and cause marked distress and impairment. The very definition of personality disorders as "chronic maladaptive patterns of behavior" implies that symptoms are stable over time; however, recent studies indicate that symptoms improve and may even completely remit over the years. Does this mean these disorders can go away? Yes and no.
Borderline personality disorder is a specific type of personality disorder characterized by impulsivity and marked instability involving interpersonal relationships, self image, and mood. It may occur together with other psychiatric disorders, including certain forms of mood disorders, substance abuse disorders, and somatization disorder, among others. It is a disorder with complex and diverse psychiatric symptoms.
In a recently published study, John Gunderson and colleagues reported that overt symptoms of borderline personality disorder substantially decreased over a 10 year period. In fact, about 85% of people with this disorder demonstrated such marked reductions in symptoms that they were considered to be "in remission." Only about 11% relapsed, suggesting that once remitted, the individuals do well. As noted, borderline personality disorder is associated with a long list of dramatic behavioral symptoms in the Diagnostic and Statistical Manual (DSM); all of these symptoms demonstrated the same pattern and time course of improvement over the 10 year period of the study. Improvement was most noticeable over the first two years and then gradually continued over the remainder of the study.
In addition to behavioral symptoms, however, borderline personality disorder is associated with substantial psychosocial and interpersonal impairment involving marriage, work, friends, etc. Although the overt symptoms substantially diminished over time, i.e., the behaviors that people see became less dramatic, the Gunderson et al. report indicated that psychosocial impairment improved only slightly and many patients continued to suffer from substantial dysfunction. Thus, were these individuals truly in "remission"? Or are the observed dramatic behaviors only one manifestation of more pervasive and persistent mental disorder? In considering this issue, we would note that the findings with borderline personality disorder are not unique to that disorder; similar long-term outcomes, including ongoing psychosocial dysfunction, were described over 50 years ago by Lee Robins in her classic work on individuals with antisocial personality disorder.
What could explain this disconnect between symptoms and function? Psychosocial impairment may be related to the consequences of the overt behavioral symptoms. Interpersonal bridges may have been burned by earlier dramatic behavioral symptoms, and some of these bridges may be impossible to repair. On the other hand, psychosocial impairment may be related to less visible functional brain changes that don't improve and influence various cognitive, emotional, social, and motivational abilities. We would argue that both possibilities are likely to be important.
The Gunderson study draws attention to two important concepts. First, some illnesses that have dramatic behavioral symptoms may also have less visible brain abnormalities that interfere with psychosocial function. Schizophrenia is an example of a disorder that has not only very dramatic "positive" symptoms such as hallucinations and delusions but also "negative" symptoms involving a variety of cognitive functions that substantially interfere with abilities to function and interact with people. Second, illnesses that begin during a person's youth can have destructive consequences that persist even after symptoms improve. Consistent with this, Read Montague and colleagues have found that individuals with borderline personality disorder have significant problems with how they process information when relating to others, particularly with maintaining interpersonal cooperation and correcting defects in cooperation when it breaks down during social interactions. These problems are associated with specific differences in how the brains of these individuals process reward and social reciprocity.
These findings have important implications and suggest that at least two types of treatments are required. First, treatments are needed that diminish the symptoms of the disorder while one is young prior to the development of hard-to-reverse psychosocial damage. Such treatments must address both the visible behavioral symptoms and also the less visible changes in brain function that involve cognitive, emotional, social, and motivational processing. In order for such treatments to be developed, substantial research involving brain mechanisms is required. In addition, treatments that focus on psychosocial rehabilitation are essential. If a person can regain the ability to work, maintain relationships, and enjoy hobbies, they are likely to feel better and be more productive. These latter types of treatments are reflected in multiple forms of psychotherapy, including cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and dialectical behavioral therapy (DBT). These approaches are mainstays in the management of individuals with personality disorders, but more effective forms of evidence-based therapy are needed.
This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.