Longitudinal Course of Borderline Personality Disorder: What Every Clinician Needs to Know

Abstract

Longitudinal research describing the course of borderline personality disorder (BPD) has radically revised psychiatry’s stigmatizing assumptions of its immutability and poor prognosis. This review outlines major findings from four of the largest, most methodologically rigorous prospective studies of BPD in childhood and adulthood to provide a scientifically informed understanding of its precursors, structure, trajectory, interaction with other psychiatric illnesses, and impact on treatment utilization and functional outcomes. BPD’s fluctuating symptoms and underlying diathesis interact over time to increase psychiatric vulnerability and divergence in developmental trajectory from peers throughout early life, resulting in higher levels of disability and adversity in adulthood. High rates of remission, low rates of relapse, and moderate but unstable recovery provide good news for its prognosis, while risk for persistence of psychiatric comorbidities, multiple suicide attempts, poor health outcomes, intensive treatment utilization, and severe functional impairment underscore its status as a serious mental illness. Longitudinal research on BPD has validated BPD as a distinct, serious, and disabling disorder, and defined clinically relevant predictors of outcome which can guide practitioners in their diagnostic disclosure, psychoeducation, and collaborative treatment planning as early as childhood. This research has also influenced more refined conceptualizations of personality disorders, which account for stable dimensions of personality traits more generally and the fluctuating course of personality disorder symptoms intermittently, pointing to alternative models of diagnosis in development.