Ten-year course of borderline personality disorder: Psychopathology and Function from the Collaborative Longitudinal Personality Study

John G. Gunderson, Harvard Medical School, McLean Hospital
Robert L. Stout, Decision Science Institute/PIRE
Thomas H. McGlashan, Yale University School of Medicine
M. Tracie Shea, Department of Veteran Affairs and Brown University Medical School
Leslie C. Morey, Texas A & M University - College Station
Carlos M. Grilo, Yale University School of Medicine
Mary C. Zanarini, Harvard Medical School, McLean Hospital
Shirley Yen, Brown University Medical School
John C. Markowitz, New York State Psychiatric Institute, Columbia University
Charles A. Sanislow, Wesleyan University
Emily B. Ansell, Yale University School of Medicine
Anthony Pinto, New York State Psychiatric Institute, Columbia University
Andrew E. Skodol, Sunbelt Collaborative and the University of Arizona College of Medicine

Abstract

Context: Borderline personality disorder (BPD) is traditionally considered chronic and intractable.

Objective: To compare the course of BPD’s psychopathology and social function with that of other personality disorders and with major depressive disorder (MDD) over 10 years. Design: A collaborative study of treatment-seeking, 18- to 45-year-old patients followed up with standardized, reliable, and repeated measures of diagnostic remission and relapse and of both global social functioning and subtypes of social functioning.

Setting: Nineteen clinical settings (hospital and outpatient) in 4 northeastern US cities.

Participants: Three study groups, including 175 patients with BPD, 312 with cluster C personality disorders, and 95 with MDD but no personality disorder.

Main Outcome Measures: The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version (the Diagnostic Interview for DSM-IV Personality Disorders– Follow-Along Version) were used to diagnose personality disorders and assess changes in them. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-up Evaluation were used to diagnose MDD and assess changes in MDD and in social function.

Results: Eighty-five percent of patients with BPD remitted. Remission of BPD was slower than for MDD (P<.001) and minimally slower than for other personality disorders (P<.03). Twelve percent of patients with BPD relapsed, a rate less frequent and slower than for patients with MDD (P<.001) and other personality disorders (P=.008). All BPD criteria declined at similar rates. Social function scores showed severe impairment with only modest albeit statistically significant improvement; patients with BPD remained persistently more dysfunctional than the other 2 groups (P<.001). Reductions in criteria predicted subsequent improvements in DSM-IV Axis V Global Assessment of Functioning scores (P<.001).

Conclusions: The 10-year course of BPD is characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning. These results inform expectations of patients, families, and clinicians and document the severe public health burden of this disorder.