Editorial
Progress in the Treatment of Borderline Personality Disorder
W John Livesley, MD1
For good reason, borderline personality disorder (BPD) is widely believed to be difficult to treat. Patients with this disorder often have difficulty engaging in treatment; they present with complex, multidimensional problems; outcome is often modest at best; and some patients seem to deteriorate rather than improve from contact with the health care system. Not surprisingly, many health care professionals feel pessimistic about treating personality disorder (PD). However, as the papers in this review suggest, such pessimism is overdone: treatment can reduce symptoms and improve quality of life. There is also considerable short-term fluctuation in symptoms and distress, and the long-term outcome for many patients is often better than originally thought, even without treatment.
Over the last decade and a half, conceptions of PD and its treatment have changed substantially. Until about 1990, psychoanalytically based therapy dominated the field, and most treatments drew heavily on psychosocial models of etiology and speculative theoretical conceptions of the disorder. This situation changed dramatically with the development of cognitive, cognitive-behavioural, and interpersonal therapies, along with increasing evidence of the value of medication. The increase in therapeutic options has been paralleled by an increase in outcome studies demonstrating evidence of efficacy. The papers in this review consider these developments and their implications.
In the first paper, Joel Paris reviews the literature on treatment outcome. Although relatively few studies are available, they offer reason for therapeutic optimism. Several different treatments and modalities, including medication, are associated with favourable outcomes. Paris also makes the useful point that BPD is a chronic disorder and should be managed as such. This points to the importance of long-term outcome studies and the need to employ therapeutic strategies that reduce chronicity, organize the environment to compensate for and minimize social and psychological difficulties, use the patient’s assets effectively, and develop relevant skills. Regrettably, such long-term outcome studies are not available, even for dialectical behaviour therapy, which is often touted as the treatment with the most evidential support. This makes it difficult to evaluate the claims of competing models. Current study designs also make it difficult to disentangle the effects of the specific features of alternative models from the generic effects of therapy. However, as Paris notes, indications that outcomes are similar across treatments points to the importance of generic influences common to all forms of therapy—a finding that is consistent with the general literature on psychotherapy outcome.
This theme is pursued in the second paper, in which I consider the general principles and strategies for treating PD. Building on Paris’ conclusions about the importance of generic influences and on evidence pointing to similar outcomes across treatments, I propose an eclectic and integrated approach to treatment that combines effective interventions from alternative models within a framework that emphasizes the importance of the nonspecific component of therapy. The implicit argument is that the treatment of PD needs to move beyond a partisan approach that argues the merits of different treatments appearing to have similar, but modest, outcomes to a systematic approach that combines intervention strategies from different models on the basis of evidence of efficacy and a systematic analysis of the most effective ways to manage the different domains of psychopathology that constitute PD.
We clearly have far to go before an effective treatment of PD is available. Nevertheless, there are good reasons to feel more hopeful than was possible only a few years ago, and the outcome for many patients could be much better than is often the case. It is unfortunate that, as evidence of treatment efficacy is increasing, specific treatment programs for BPD are becoming less available. The evidence suggests that the disorder is prevalent and has a mortality rate of approximately 10%. If a physical disorder affecting young adults had a 10% mortality rate, there would be public demands for more dedicated treatment services and research
Author
1. Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
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