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Progress in the treatment of borderline personality disorder

  • Peter Fonagy (a1) and Anthony Bateman (a2)
Summary

We outline recent evidence suggesting that the natural course of borderline personality disorder is more benign than formerly believed. We explore possible reasons for the change in findings which include both the iatrogenic effects of earlier treatment models and the recent availability of effective interventions. Clinicians should be optimistic about improvement and long-term outcomes.

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Copyright
Corresponding author
Peter Fonagy, Freud Memorial Professor of Psychoanalysis, Sub-Department of Clinical Health Psychology, University College London, Gower Street, London WCIE 6BT, UK. E-mail: e.allison@ucl.ac.uk
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Declaration of interest

The authors are in receipt of a grant from the Borderline Personality Disorder Foundation to support a randomised controlled trial of intensive out-patient psychotherapy.

Footnotes
References
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Bartels, A. & Zeki, S. (2004) The neural correlates of maternal and romantic love. Neuroimage, 21, 11551166.
Bateman, A. W. & Fonagy, P. (1999) The effectiveness of partial hospitalization in the treatment of borderline personality disorder – a randomised controlled trial. American Journal of Psychiatry, 156, 15631569.
Bateman, A. W. & Fonagy, P. (2001) Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. American Journal of Psychiatry, 158, 3642.
Bateman, A. W. & Fonagy, P. (2004) Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment. Oxford: Oxford University Press.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., et al (2004) The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics. Journal of Personality Disorders, 18, 5272.
Fonagy, P. & Bateman, A. (2006) Mechanisms of change in mentalisation based therapy with BPD. Journal of Clinical Psychology in press.
Lieb, K., Zanarini, M. C., Schmahl, C., et al (2004) Borderline personality disorder. Lancet, 364, 453461.
Shea, M. T., Stout, R. L., Yen, S., et al (2004) Associations in the course of personality disorders and Axis I disorders over time. Journal of Abnormal Psychology, 113, 499508.
Stone, M. H. (1990) The Fate of Borderline Patients: Successful Outcome and Psychiatric Practice. New York: Guilford Press.
Zanarini, M. C., Frankenburg, F. R., Hennen, J., et al (2003) The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160, 274283.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Progress in the treatment of borderline personality disorder

  • Peter Fonagy (a1) and Anthony Bateman (a2)
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eLetters

How symptom-free is "remission"?

AhmedS Huda, Locum Consultant Psychiatrist
01 February 2006

In the editorial about borderline personality disorder (Fonagy & Bateman 2006), they state that "after 6 years, 75% of patients diagnosed with borderline personality disorder ... achieve remission by standardiseddiagnostic criteria" based on 2 studies. I managed to acquire one of the references they quoted, Zanarini et al's study (Zanarini et al 2003).I understand by the word "remission" a state of welll-being that is largely symptom-free (even if this state is temporary) rather than a levelof psychopathology that fails to meet diagnostic criteria (but may still include distressing symptoms).In the long-term study of outcome with borderline personality disorder mentioned above(Zanarini et al 2003)73.5% of the surviving borderline personality disorder subjects ( 11 out of the 290 borderline personality disorder subjects killed themselves) no longer met the criteria for that diagnosis by the end of 6 years. the authors of that study indeed called this "remission. However the study also showed significant levels of psychopathology remained in the groupafter 6 years. For example, 41.3% experienced chronic or major depression,42.9% suffered chronic anger or frequent angry acts, 34.9% had chronic anxiety, 55.6% had miscellaneous impulsive patterns of behaviour (excluding self harm or substance abuse). Now is this remission in the sense that we apply to, for example, major depressive disorder where research subjects often have to be largely symptom-free? Would not a better description be that "the level of severity reduces to a large extent but a significant amount of distress and psychopathology remains"? I understand the authors are probably trying to injext some optimism in the way psychiatrists view patients with borderline personality disorder but this is best done by not overstating the case with overly optimistic terminology.

REFERENCES

Fonagy, P. & A. Bateman (2006)Progress In The Treatment of Personality Disorder. The British Journal of Psychiatry 188: 1-3.

Zanarini, M. C., Frankenburg, F. R., Hennen, J., et al (2003) The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160, 274 -283
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