The course of BPD

Selasa, 12 Januari 2010

There is surprisingly little information about the childhood precursors of adult PD. The Collaborative Longitudinal Personality Disorder Study suggests that a history of MDD with insidious onset in adolescence and recurrence, chronicity and progressive severity is particularly likely to be associated with adult PD (Skodol et al. 1999). A study of a random sample of 551 youths (Kasen et al. 2001) reported that the presence of MDD in adolescence increased the likelihood of the diagnosis of dependent PD, ASPD, passive-aggressive and histrionic PD, but not BPD. However, the odds ratios in this report were adjusted for childhood maltreatment and if MDD in BPD was principally a reaction to childhood abuse then MDD would not be observed to be associated with BPD in this analysis. A longitudinal study of 407 adolescents (208 boys and 199 girls) recruited from a community sample looked at the predictive significance of internalizing and externalizing symptoms for the development of Cluster B characteristics (Crawford et al. 2001b). The pattern for girls indicates that externalizing symptoms in adolescence (12–17) predict Cluster B symptoms
at 17–24, even when earlier Cluster B symptoms are controlled for. However,
early (10–14) internalizing symptoms (anxiety and depression) also predicted
Cluster B symptoms in adolescence. The pattern for girls at least appears from
this study to be that early internalizing symptoms predict adolescent Cluster B
symptoms but adolescent externalizing symptoms predict adult Cluster B
symptoms. The findings are intriguing because for boys there appears to be no
forward prediction of Cluster B symptoms from either internalizing or externalizing
symptoms.

This finding complements the retrospective observation that antisocial behaviour in female adolescents is associated with BPD symptoms in early adulthood (Goodman et al. 1999). There are those who recommend the establishment of the diagnosis of BPD in childhood. A review of the literature (e.g. Ad-Dab’bagh and Greenfield, 2001) supports the creation of a new diagnostic label to describe a population of children whose symptoms are currently subsumed under the labels ‘borderline’ or ‘multiple complex developmental disorder.’ A full characterization of the syndrome, including its evolution, would require prospective studies and may differ from the known
evolution for PD and/or pervasive developmental disorders.

There are a number of studies of the course of BPD although most have methodological problems. The studies tend to show reasonable stability for BPD, although less than one might expect for a PD (Paris 1998a; Grilo et al. 2000). The clinical course is somewhat heterogeneous even within samples. Borderline patients improve symptomatically over time. One exceptionally long (27-year) follow-up (Paris and Zweig-Frank 2001) showed that borderline patients continued to improve in late middle-age with only 8% of the BPD sample meriting diagnosis of BPD. Long-term outcome in this study was associated with severity of the disorder and the quality of adaptation (functioning) at the start of the study but not with parenting quality or child abuse or trauma (Zweig-Frank and Paris, 2002).

A definitive study (Zanarini et al. 2003) followed the syndromal and sub-syndromal phenomenology of 362 adult in-patients with PD over 6 years of prospective follow-up. The cohort was assessed with the Revised Diagnostic Interview for Borderlines (DIB-R) and BPD module of the Revised Diagnostic Interview for DSM-III-R Personality Disorders. Of these patients, 290 met DIB-R and DSM-III-R criteria for BPD and 72 met DSM-III-R criteria for other axis II disorders (and neither criteria set for BPD). Over 94% of the total surviving subjects were reassessed at 2, 4, and 6 years by interviewers blind to previously collected information. Of the subjects with BPD over one-third met the criteria for remission at 2 years, half at 4 years, and over two-thirds at 6 years. When the entire follow-up period was considered almost three quarters could be considered to have recovered at some stage and only 6% of those with remissions experienced recurrences. Importantly, the comparison subjects with other axis II disorders did not develop BPD over the course of the follow-up. The patients with BPD had declining rates of symptoms but remained symptomatically distinct from the comparison subjects. Comparing the rate at which categories of symptoms decline, the study found impulsive symptoms to resolve most quickly and affective symptoms to be the most chronic. Cognitive and interpersonal symptoms were intermediate in the rate of decline. The results suggest that symptomatic improvement is both common and stable, even among the most disturbed borderline patients, and that the symptomatic prognosis for most, but not all, severely ill borderline patients is better than previously recognized.

This contrasts with the relative stability of the disorder in late adolescence and young adulthood. In a study of the stability of Cluster B symptoms between the ages of 12 and 20, Crawford and colleagues reported higher stability for PD symptoms than for Axis I symptoms (internalizing and externalizing) (Crawford et al. 2001a). The stability for Cluster B symptoms was 0.63 for boys and 0.69 for girls whereas the stability for internalizing symptoms was 0.24 and 0.39 and externalizing symptoms 0.32 and 0.38 for girls and boys respectively. These findings underscore the persistence of normal and abnormal personality constellations. The lower stability of Axis I symptoms may be disguised by some developmental heterotypy (i.e. different manifestations of the same underlying disorder at different developmental stages). Nevertheless, the stability of Cluster B disturbance is striking and many might interpret this as supporting the link of Cluster B with biologically predetermined personality dispositions such as novelty seeking where genetic loadings are high
(Livesley et al. 1998).

Borderline personality disorder patients who have been sexually abused in childhood (Paris et al. 1993; 1994a,b) or have been victims of incest (Stone, 1990) have a poor prognosis. If the patient’s first psychiatric contact takes place at an early age (Links et al. 1993) and his/her symptoms are chronic, spontaneous recovery is less likely (McGlashan 1992). Phenomenological factors that predict poor outcome include higher levels of affective instability, magical thinking, and aggression in relationships (McGlashan 1992), impulsivity and substance abuse (Links et al. 1993), and greater severity of disorder (Links et al. 1998). Further, if the patients have co-morbid schizotypal (McGlashan 1986), antisocial (Stone 1993), or paranoid features, then the prognosis is likely to be poor (Links et al. 1998). The evidence consistently suggests that even if the diagnosis of BPD ceases to be applicable, patients tend to remain functionally seriously impaired (Skodol et al. 2002c).