At the 2012 annual meeting of the American Psychiatry Association, held in Philadelphia, Pennsylvania, Medscape spoke with Christopher J. Hopwood, PhD, Assistant Professor in the Department of Psychology at Michigan State University, on new research that suggests a silver lining for patients with borderline personality disorder (BPD).
Medscape: Can you give us a brief summary of the work on BPD that you presented today?
Dr. Hopwood: A interesting finding that has emerged recently is the idea that personality disorders are less stable than previously thought; people's symptoms actually decline eventually, and they get better, which is really good news.
I presented on the stability of underlying personality traits among people with BPD compared with people with other personality disorders. It's interesting from a scientific perspective, because the issue of normal trait stability has been a long-standing debate. One of the findings has been that personality traits are generally stable, meaning they're relatively consistent over time in adulthood. But new findings show that people with clinical conditions tend to have less stable personality traits than people without such conditions.
Because BPD is defined in part by such traits as instability of emotions, interpersonal behavior, and self-esteem, a hypothesis is that instability in the underlying personality system might be implicated as an etiologic factor in BPD. And in fact, we know that normal trait instability over time has heritable components. So it might be that some people have a propensity to have less stable personalities and that people who are extreme in this propensity maybe end up demonstrating symptoms that we describe as BPD. That is, the characteristic instability we see in BPD may be a consequence of instability in the underlying normative trait system.
Medscape: Meaning that everyone has personality trait variability, but that in some people this variability is more extreme, pushing them over the edge into a pathology? But also that this instability isn't consistent, or stable, throughout one's life?
Dr. Hopwood: Yes. What we know from cross-sectional research is that people with BPD are more neurotic, but our research shows that these people also change more in neuroticism over time. Neuroticism is a trait involving negative emotions, such as anger, sadness, and anxiety. So those with BPD were more neurotic at baseline than the other sample, but their neuroticism also declined much more rapidly. This suggests that the average level of neuroticism might be an important factor when considering whether a person has BPD pathology, but also that variability in this trait over time might be a relevant and independent factor.
Medscape: What other traits are important, particularly in terms of stability, when assessing BPD?
Dr. Hopwood: It's interesting, because there are different kinds of stability. We looked at average changes over time, or absolute stability, but there is also differential stability -- the rank ordering of people over time. For example, when considering 2 people, person A may be more neurotic than person B at baseline, but at follow-up person B may be more neurotic than person A. Whereas absolute stability is evaluated by comparing group means over time, differential stability is assessed by computing retest correlations on a trait over time.
There is also individual-level stability, which refers to variability around a mean change. So our study showed that individuals with BPD change, on average, more than others, but different people within those groups may change more rapidly than others. The amount of variability within a group in change over time on a trait is referred to as individual level-stability.
Each of these kinds of stability are independent of one another and may indicate different psychological processes. It turns out that different traits have different stability effects when patients with BPD are compared with other groups, depending on which kind of stability you're looking at. For example, across 2 longitudinal samples, conscientiousness changes more in terms of rank order and individual stability for patients with BPD than for those with other personality disorders. But it's not all clear yet, and we're still working on this.
Medscape: You looked at stability in BPD over 16 years. What does the typical disease course look like in BPD? What are the chances of remission?
Dr. Hopwood: Mary Zanarini just published on this in The American Journal of Psychiatry. In this paper she builds on previous findings from her McLean Study of Adult Development, as well as other studies, such as the Collaborative Longitudinal Personality Disorders Study, showing that BPD symptoms decline more rapidly than was once thought. She also showed, however, that some patients have recurrences despite an initial remission, and that functioning does not always improve despite symptom remission.
So this is a mixed picture. On the one hand, when you identify individuals with BPD at their worst, I think we can be optimistic that they will improve, particularly with treatment. On the other hand, it is a pernicious disease that is highly disruptive to individuals' lives, and we still have a lot to learn about how to best help individuals with BPD.
In terms of clinical course, generally speaking BPD symptoms are most severe during adolescence, and they tend to decline over time. This tracks very nicely with the course of normal personality traits: Adolescence is typically a time of high neuroticism, low agreeableness, and low conscientiousness, but this tends to change and improve over time.
BPD remains one of the most severe conditions in psychiatric classification. However, many psychosocial treatments for BPD have proven effective in randomized controlled trials in the past couple of decades, including dialectical behavior therapy, mentalization-based therapy, transference-focused psychotherapy, and cognitive therapy. Although we still have a long way to go to better understand how to benefit individuals with BPD, recent findings on course and remission from longitudinal research, coupled with the development of effective treatments, permits more optimism than ever about the ability of clinicians to treat individuals with this difficult condition.
- Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. 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;169:476-483. Abstract