The Patient with Borderline Personality Disorder
Anthony W. Bateman
Few areas of psychiatric investigation have seen such radical progress in the field of personality disorder (PD), particularly the understanding and treatment of borderline personality disorder (BPD). The advances in knowledge have been influenced and propelled by the discovery of relatively effective outpatient1,2 and partial hospital3 psychosocial treatments shown to accelerate improvement and the increasing recognition that the course of the disorder is not as chronic and malign as hitherto believed. Taken together, this emerging knowledge has resulted in a reappraisal of treatment contexts, organization of treatment, and focus of services for BPD. Until the 1990s, long-term inpatient treatment for BPD was considered desirable. Many hospitals offered inpatient treatment programmes lasting a year or more. This is now rare. The loss of long-term inpatient treatment for BPD, introduced for financial rather than clinical reasons, may inadvertently have led to significant improvement in the outcomes for the condition. In this chapter, the author will first explore this controversial suggestion. Second, he will consider the service changes in terms of an improving evidence base. Finally, he will discuss the current role of inpatient psychiatry in the treatment of BPD.
Borderline Personality Disorder
The key deficits, as opposed to descriptive characteristics, associated with BPD are normally thought to include impulsiveness, difficulty in managing emotions, and difficulties in relationships.4 It has been suggested that these vulnerabilities in part arise out of problems with mentalization, that is a limited ability to perceive mental states in self and others accurately.5 They may also be linked to problems with differentiating self and others and identity diffusion, which some authors see as central to BPD.6, 7, 8 Certainly, difficulties with distinguishing self and others in BPD have been demonstrated in analog studies using film clips9 and narratives of childhood experience.10
The development of mentalizing abilities has been discussed in detail elsewhere.5,11 On the whole, the capacity to mentalize is a developmentally determined skill. Shutting down of mentalizing or inhibition of its development commonly occurs in response to attachment trauma. It is quite likely that high levels of arousal following traumatic experience contribute to suppressing the functioning of the frontal areas of the brain that normally underpin mentalization.12,13 In effect, an interdependent process between environmental factors and neurobiologic development determines both an individual’s baseline capacity to mentalize and the threshold at which their ability is lost during emotional states and in other stressful circumstances.
This developmental perspective is supported by family studies, a number of which have identified factors that may be important in the development of BPD. However, few of the studies point to the specific features of parenting that create a vulnerability for BPD. Physical, sexual, and emotional abuse all occur in a family context and high rates are reported in BPD.14 Overall researchers have concluded that abuse alone is neither necessary nor sufficient for the development of BPD and that predisposing factors and contextual features of the parent-child relationship are likely to be mediating factors in its actual development. Parental responses play an important role in the pathogenetic effects of abuse with parental responsiveness (believing the reports, protecting, and not expressing high levels of anger) following reports of abuse promoting more rapid adjustment15 and lack of emotional responsiveness
as well as low support and inadequate validation possibly potentiating the effects. Therefore, caregiver response to the abuse may be more important than the abuse itself in long-term outcome.16
as well as low support and inadequate validation possibly potentiating the effects. Therefore, caregiver response to the abuse may be more important than the abuse itself in long-term outcome.16
Taking all this into account, the mentalization approach to BPD predicts that it is not the fact of maltreatment but it is more the family environment that discourages coherent discourse concerning mental states and it is this that is likely to predispose the child to BPD—nonmentalizing processing leads to nonmentalizing responses. The mentalizing model suggests that individuals with BPD, while able to mentalize, are more likely to abandon the capacity under high emotional arousal, for example, in response to maltreatment, because mentalization was not well established during the first decade of life in part as a consequence of early maltreatment and its associated problems. The impact of trauma is most likely to be felt as part of a more general failure of consideration of the child’s perspective through neglect, rejection, excessive control, unsupportive relationship, incoherence, and confusion. These can devastate the experiential world of the developing child and leave deep scars which are evident in their later social cognitive functioning and behavior.
This formulation converges with that advanced by Marsha Linehan17 concerning the assumption of the invalidating family environments and developed further by Alan Fuzzetti et al.18,19 These workers report that parental invalidation, in part defined as the undermining of self-perceptions of internal states, was not only associated with the young person’s reports of family distress, their own distress, and psychological problems but also with aspects of social cognition, namely their ability to identify and label emotion. Along with other aspects contributing to the complex interaction described as invalidating, this amounts to a systematic undermining of a person’s experience of their own mind by the replacement of their mind with another or a failure to encourage discrimination between their own feelings and experiences and those of the caregiver.
In BPD, inhibition of mentalization occurs specifically in the context of intimate attachment relationships. Although the deficit in mentalizing, characteristic of BPD, is partial, temporary, and relationship-specific, it is a core problem of the disorder. This is not a trivial point clinically because any treatment or any interactive context in which relationships are of significance, for example, psychotherapy or inpatient milieu will result in loss of mentalizing following stimulation of the attachment relationship. As a consequence, psychotherapies focusing on the relationship between patient and therapist and contexts intrinsically operating a high-pressure relational environment such as inpatient facilities might cause harm to borderline patients. There is some evidence for this.
LONG-TERM INPATIENT ADMISSION AND THE REALITY OF IATROGENIC HARM
Two carefully designed fully powered prospective studies have highlighted the inappropriateness of the attitudes that confined individuals with severe PD to the margins of even generous health care systems.20 Most patients with BPD experience a substantial reduction in their symptoms far sooner than previously assumed.21,22 This is in marked contrast to the evidence about the longitudinal course presented in the 1980s which suggested a chronic course leading to “burnt out borderlines.” It transpires that after 6 years 75% of patients diagnosed with BPD achieve remission by standardized diagnostic criteria. Patients with BPD can undergo remission—a concept that had previously been solely used in the context of Axis I pathology. Approximately 50% remission rate has occurred by 4 years but the remission is steady (10% to 15% per year). Recurrences are rare, perhaps no more than 10% over 6 years. This contrasts with the natural course of many Axis I disorders, such as affective disorder, where improvement may be somewhat more rapid but recurrences are common. In the Collaborative Depression Study, 30% of the patients had not recovered at 1 year, 19% at 2 years, and 12% at 5 years.23
While improvements of BPD are substantial, it should be noted that it is symptoms such as impulsivity and associated self-mutilation and suicidality that show dramatic change and not affective symptoms or social and interpersonal functioning. The dramatic symptoms (self-mutilation, suicidality, quasipsychotic thoughts often seen as requiring urgent hospitalization) recede but abandonment concerns, sense of emptiness, relationship problems, and vulnerability to depression are likely to remain present in at least half the patients. When dramatic improvements occur, they sometimes occur quickly, quite often associated with relief from severely stressful situations.24
It seems that certain comorbidities undermine the likelihood of improvement;25 the persistence of substance use disorders decreases the likelihood of remission, suggesting that the latter must be treated.
But it also seems that treatment contexts can also subvert natural improvement. Negative findings to emerge from the literature in relation to intensive inpatient treatment concern the greater efficacy of briefer periods of hospitalization,26 the general ineffectiveness of brief hospital admissions motivated by suicide threats,27 and the uncertain value of combining short intensive inpatient admissions with structured psychotherapeutic interventions28 in which only 48% of patients show clinically significant improvement (but see later). Chiesa et al. compared two models of psychosocial intervention for PD. People with PD were allocated (but not randomly) either to a one-stage treatment model (inpatient for 1 year with no specialist after care) or to a two-stage model (6-month inpatient admission followed by outreach treatment), and were prospectively compared. It was found that the subjects in the two-stage sample did significantly better on global assessment of mental health and in social adjustment at 12 months. Subjects with BPD allocated to the two-stage model improved significantly more than such patients in the one-stage model. The pattern was maintained in follow-up. Patients in shorter admission programme were found to self-mutilate, attempt suicide, and be readmitted significantly less at 24- and 36-month follow-up than patients in the longer-term inpatient group and these differences have now been shown to continue at 6-year follow-up.29 In addition, patients admitted to the shorter programme were 5.5 times less likely to drop out early than those admitted to the more intensive admission.30 Inevitably, the better outcome and less intensive intervention was more cost-effective.31
But it also seems that treatment contexts can also subvert natural improvement. Negative findings to emerge from the literature in relation to intensive inpatient treatment concern the greater efficacy of briefer periods of hospitalization,26 the general ineffectiveness of brief hospital admissions motivated by suicide threats,27 and the uncertain value of combining short intensive inpatient admissions with structured psychotherapeutic interventions28 in which only 48% of patients show clinically significant improvement (but see later). Chiesa et al. compared two models of psychosocial intervention for PD. People with PD were allocated (but not randomly) either to a one-stage treatment model (inpatient for 1 year with no specialist after care) or to a two-stage model (6-month inpatient admission followed by outreach treatment), and were prospectively compared. It was found that the subjects in the two-stage sample did significantly better on global assessment of mental health and in social adjustment at 12 months. Subjects with BPD allocated to the two-stage model improved significantly more than such patients in the one-stage model. The pattern was maintained in follow-up. Patients in shorter admission programme were found to self-mutilate, attempt suicide, and be readmitted significantly less at 24- and 36-month follow-up than patients in the longer-term inpatient group and these differences have now been shown to continue at 6-year follow-up.29 In addition, patients admitted to the shorter programme were 5.5 times less likely to drop out early than those admitted to the more intensive admission.30 Inevitably, the better outcome and less intensive intervention was more cost-effective.31
So what could be made of this evidence? Could the apparent improvement in the course of the disorder over the last decade be accounted for by harmful treatments, in this case prolonged inpatient treatment being less frequently offered? If correct, this is possibly more a consequence of the changing pattern of health care particularly in the United States32 than recognition by clinicians of the possibility of iatrogenic deterioration and subsequent avoidance of damaging side effects. This suggestion is speculative but it requires further consideration although evidence from the recent longitudinal studies does not tell whether interventions that were delivered were effective or inappropriate.
Mechanism of Harm
If it is correct that borderline patients are more sensitive to protracted inpatient treatment than other groups of patients as suggested by the evidence, entering inpatient facilities is likely to be a highly stressful event. The very act of casting off everyday responsibilities to interact with a large group of patients is likely to stimulate the attachment system to a degree that easily overwhelms even the most robust individual. As previously mentioned, from a mentalizing perspective, the borderline patient is uniquely sensitive to stimulation of the attachment system and a rapid reduction in mentalizing capacity is inevitable when this occurs. Once mentalizing has been reduced, the mind goes “off line” and behavioral responses to stress are triggered.
The fact that starting treatment in an inpatient facility reduces mentalizing has been given more direct support from a study in Belgium. Vermote et al.33 studied a group of patients with personality disorder admitted to a 1-year inpatient treatment programme. Defining three groups of patients—low, medium, and high symptom level—they identified different trajectories of treatment.
A small group of low-level patients presented few symptoms at the outset, had a high level of borderline personality organization, and were in crisis when admitted to the hospital. They recovered fast and did not need prolonged inpatient treatment for symptom amelioration.
The group with a high frequency of symptoms had a low-level borderline personality organization. Post hoc tests showed that they were considerably more paranoid, hostile, and vindictive than the other groups. The trajectory of this group is remarkable. They only improved in the last quarter of the treatment, an improvement that continued in the posttreatment phase.
The group with a moderate level of symptoms showed two distinct trajectories—one with a good outcome and the other with a poor outcome. This was not simply related to severity of borderline pathology and therefore, the authors investigated other characteristics finding that the good outcome group corresponded to those patients with dismissive avoidant attachment styles. The patients were characterized by avoidant, paranoid, schizoid, and narcissistic features. These features are similar to Blatt’s categorization of an introjective group,34,35 who are thought to do better with exploratory/interpretive therapy.36 The poor outcome group showed all the features of BPD but with anaclitic features rather than controlling an introjective attitude. They reported more sexual abuse and other early traumas. Their poor outcome was considered to be related to the lack
of support early in treatment. Vermote concludes that these patients were included too soon in a classic psychoanalytic interpretive group approach and were easily overwhelmed by the intensity of involvement on entering the inpatient facility.
of support early in treatment. Vermote concludes that these patients were included too soon in a classic psychoanalytic interpretive group approach and were easily overwhelmed by the intensity of involvement on entering the inpatient facility.
During the first few weeks of admission all patients showed a reduction in mentalizing abilities as evidenced by the reflective function scale and the object relation inventory. Interestingly therapists rated this period as positive in contrast to the patients who only felt the considerable distress. This phenomenon of worsening of symptoms at the beginning of treatment has been considered as regression in the service of progression by therapists, but it is also the most likely cause of the high drop-out rate reported in studies of intensive treatments (36% in this study) as patients attempt to restabilize by leaving a toxic environment. This early reduction in mental capacity to manage emotional states should not be conflated with changes over the longer term. Gabbard et al.37 observed little evidence of regression following prolonged inpatient treatment for PD. In a prospective study of 216 patients with severe PD treated at the Menninger Clinic for variable lengths of time in two psychoanalytically orientated inpatient units, they found positive change at discharge and 1-year follow-up, with no evidence of deleterious effects due to regression and dependency. But this finding applied to those patients who remained in the treatment programme and not to those who left in the first few weeks. So once the initial period of admission to inpatient treatment has been successfully negotiated borderline patients may do well.
Related posts:
The Ins and Outs of 200 Years of Psychiatric Hospitals in the United States
Psychosocial Approaches in Inpatient Psychiatry
Legal Issues in Inpatient Psychiatry
Psychiatric Education on the Inpatient Unit
Recurrently Readmitted Inpatient Psychiatric Patients: Characteristics and Care
Evaluation and Management of Substance Use Disorders on the Inpatient Psychiatric Unit
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