Course Of Borderline Personality Disorder Research Articles

The course of borderline personality disorder from adolescence to early adulthood: A 5-year follow-up study

BackgroundStudies of the medium- to long-term clinical and functional course for treatment-seeking adolescents with borderline personality disorder (BPD) are lacking. This study aims to outline the psychopathological and functional status of participants, five years after being diagnosed with BPD during adolescence. MethodsParticipants were originally enrolled in a randomized clinical trial that compared mentalization-based group treatment with treatment as usual for adolescents with BPD. Semi-structured interview assessments at five-year follow-up included the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders. Attention deficit hyperactivity disorder (ADHD), alcohol, substance and tobacco use, posttraumatic stress disorder (PTSD), complex PTSD, and general functioning were assessed using self-report instruments. Results97 of the original sample of 111 participants (87%) participated. They were aged 19–23 years. The most prevalent disorders were ADHD (59%), any personality disorder (47%) of which half continued to meet criteria for BPD (24%), anxiety disorders (37%), depressive disorders (32%), PTSD or complex PTSD (20%), schizophrenia (16%), and eating disorders (13%). Only 16% did not meet criteria for any mental disorder. Approximately half of the sample were in psychological and/or psychopharmacological treatment at the time of follow-up. Their general functioning remained impaired, with 36% not engaged in education, employment or training (NEET), which is nearly four times the rate of NEET in the same age group in the general population. ConclusionsAlthough stability of the categorical BPD diagnosis is modest, adolescents meeting diagnostic criteria for BPD show a broad range of poor outcomes at five-year follow-up. BPD appears to be a marker of general maladjustment during adolescence and a harbinger of severe problems during the transition to young adulthood. Early intervention programs for adolescents diagnosed with BPD should focus upon a broad range of functional and psychopathological outcomes, especially social and vocational support, rather than the narrow BPD diagnosis.

Physical health, primary care utilization and long-term quality of life in borderline personality disorder: A 10-year follow-up study in a Spanish sample

ObjectiveWe aimed to study physical health and primary care utilization in the long-term course of borderline personality disorder (BPD) and their impact on quality of life (QOL) in a Spanish clinical sample. MethodsThis study is part of a longitudinal study following a clinical cohort with BPD. A total of 41 participants were re-evaluated at 10-year follow-up, when current medical conditions, primary care utilization, and quality of life were assessed. Comparative population data were extracted from the Catalan Health Survey ESCA. Results68% of BPD patients reported physical health problems, and 32% informed of multiple medical illnesses at follow-up. Higher rates of musculoskeletal disorders and frequent use of general practitioner (GP) consultations were reported by BPD patients compared to the general population. Differences in physical health and use of primary care services between remitted and non-remitted BPD patients were not significant. BPD remission was independently associated with better long-term QOL. Comorbid somatic diseases worsened the long-term QOL of non-remitted BPD patients. ConclusionChronic somatic conditions are prevalent in people with BPD and interact negatively with persistent BPD pathology, worsening their QOL in the long-term. Health care strategies in the assistance of long-lasting BPD patients are recommended.

Age dependent effects of early intervention in borderline personality disorder in adolescents.

Psychological treatments for young people with sub-threshold or full-syndrome borderline personality disorder (BPD) are found to be effective. However, little is known about the age at which adolescents benefit from early intervention. This study investigated whether age affects the effectiveness of early intervention for BPD. N = 626 participants (M age = 15 years, 82.7% female) were consecutively recruited from a specialized outpatient service for early intervention in BPD in adolescents aged 12- to 17-years old. DSM-IV BPD criteria were assessed at baseline, one-year (n = 339) and two-year (n = 279) follow-up. Older adolescents presented with more BPD criteria (χ2(1) = 58.23, p < 0.001) and showed a steeper decline of BPD criteria over the 2-year follow-up period compared with younger adolescents (χ2(2) = 13.53, p = 0.001). In an attempt to disentangle effects of early intervention from the natural course of BPD, a parametrized regression model was used. An exponential decrease (b = 0.10, p < 0.001) in BPD criteria was found when starting therapy over the 2-year follow-up. This deviation from the natural course was impacted by age at therapy commencement (b = 0.06, p < 0.001), although significant across all ages: older adolescents showed a clear decrease in BPD criteria, and young adolescents a smaller decrease. Early intervention appears effective across adolescence, but manifests differently: preventing the normative increase of BPD pathology expected in younger adolescents, and significantly decreasing BPD pathology in older adolescents. The question as to whether developmentally adapted therapeutic interventions could lead to an even increased benefit for younger adolescents, should be explored in future studies.

Timing of imagery rescripting during schema therapy for borderline personality disorder: the LUCY trial.

Early childhood adversity plays an important role in the etiology of borderline personality disorder (BPD). Current evidence suggests that trauma treatment for patients with BPD can be performed safely and that early trauma treatment has a positive effect on the course of PD. However, there is a scarcity of RCTs comparing the effects of the timing of trauma treatment during schema therapy (ST) for BPD on BPD severity. Therefore, the LUCY trial investigates the effects of the timing of trauma treatment by comparing early trauma treatment using imagery rescripting (ImRs) on the course of BPD during ST to trauma treatment in the middle of the treatment course. In this multicenter RCT, two conditions are compared among 73 individuals with BPD. The participants receive combined individual and group ST in both conditions. However, in condition (A), participants directly start ImRs in the individual sessions in months 2-4, and in condition (B), participants receive ST-as-Usual (STAU), in which ImRs is not allowed during months 2-4. The treatment follows ST treatment protocols, consists of a fixed combination of individual sessions and group sessions with a maximum of nine patients, and has a maximum duration of 25 months. The primary outcome is change in BPD severity, which is assessed using the Borderline Personality Disorder Severity Index-5 by independent raters blinded to the treatment. Secondary outcome measures include treatment retention, disconnection/rejection schemas, general functioning, posttraumatic stress disorder symptoms, general psychopathological complaints, quality of life, happiness, schemas, and schema modes. Multilevel analysis will be performed to analyze and compare changes in BPD severity between conditions and generalized linear mixed model analyses to test predictors and moderators. This study will increase the knowledge on whether trauma treatment early in therapy positively affects the course of BPD manifestations during ST. When the early application of ImRs leads to a faster decrease in BPD manifestations, the treatment of BPD patients might be shortened, leading to improved treatment outcomes and decreased healthcare expenses. Moreover, the planned sub-studies will expand our knowledge of how ST works and the factors that influence the outcome of treatment.

The meaning of lithium and naltrexone pharmacotherapy in the treatment of borderline personality disorder – a narrative review

Introduction: Borderline personality disorder (BPD) affects approximately 1%-3% of the population. As the most common personality disorder, BPD features behavioural, emotional and social dysfunctions. It often co-occurs with self-harm, suicidal tendencies and substance abuse. To date, pharmacological treatment does not provide sufficient therapeutic effects. The aim of our study is to analyse the neurobiological, genetic and environmental components in the aetiopathogenesis of BPD and to collect data on the innovative use of lithium and naltrexone in the therapy of BPD. Methods: Basing on PubMed and Google Scholar databases using the following keywords: borderline, lithium, naltrexone for papers published from 1979 to 2022. Results: Difficult childhood, and emotional, sexual and physical abuse are the strongest predictors of BPD development. The core symptoms of BPD may be related to dysfunction of the serotonin, dopaminergic, endogenous system and opioid systems. Variation in 5-HTT, COMT, FKBP5 and oxytocin receptor genes may influence the course of BPD. Imaging studies have shown structural and functional abnormalities in the prefrontal cortex, amygdala and hippocampus. Lithium reduces impulsivity, aggression, suicidal tendencies and self-harm in BPD. Naltrexone may effectively reduce self-harm without suicidal tendencies, impulsivity, substance abuse and suicidality. Conclusions: No unified model has been developed to account for environmental, genetic and neurobiological components in the pathogenesis of BPD. Understanding the mechanisms is a crucial step towards personalising treatment. The use of lithium and naltrexone may have positive therapeutic effects. Randomised clinical trials are required to establish the efficacy and safety of both drugs in long-term treatment. Keywords: borderline, lithium, naltrexone

Parental Reports of Physically Self-Destructive Behavior in the Offspring of Patients With Borderline Personality Disorder and Other Personality Disorders.

The main aim of this article is to compare the prevalence of four forms of physically self-destructive behavior in the offspring of parents with borderline personality disorder (BPD) and compare them to the offspring of parents with other personality disorders (OPD). At the 4- and 6-year waves in a prospective study of the long-term course of BPD, participants were asked to report on the self-destructive behaviors of their children using the Childhood Self-Destructiveness Scale. A total of 68 parents were interviewed regarding 131 children, 104 of whom were offspring of parents with BPD (n = 55) and 27 were offspring of parents with OPD (n = 13). BPD parents reported significantly more self-injury and substance abuse in their children than OPD parents. The results from this study suggest that both direct and indirect forms of self-destructive behavior are both more common and quite specific for the children of parents with BPD.

Current Clinical Psychopharmacology in Borderline Personality Disorder.

Background Patients with Borderline Personality Disorder (BPD) manifest affective and behavioral symptoms causing personal distress, relationship difficulties, and reduced quality of life with global functioning impairment, mainly when the disease takes an unfavorable course. A substantial amount of healthcare costs is dedicated to addressing these issues. Many BPD patients receive medications, mostly those who do not respond to psychological interventions.Objective Our aim was to assess the efficacy of the most used strategies of pharmacological interventions in BPD with a comprehensive overview of the field.Methods We searched the PubMed database for papers focused on the most used psychotropic drugs for BPD. We included randomized controlled trials and open studies in adult patients with BPD, focusing on the efficacy and tolerability of single classes of drugs with respect to specific clinical presentations that may occur during the course of BPD.Results Specific second-generation antipsychotics (SGAs) or serotonergic antidepressants can be effective for different core symptoms of BPD, mainly including mood symptoms, anxiety, and impulse dyscontrol. Some atypical antipsychotics can also be effective for psychotic and dissociative symptoms. Specific antiepileptics can be useful in some cases in treating different BPD symptoms, mainly including mood instability, impulsiveness, and anger.Conclusion No medication is currently approved for BPD, and clinicians should carefully assess the benefits and risks of drug treatment. Further studies are needed to identify specific personalized treatment strategies, also considering the clinical heterogeneity and possible comorbidities of BPD.

Towards Phenotyping Treatment Response in Borderline Personality Disorder: Quantitative Language Analysis of Clinical Interviews

Longitudinal, within-subject assessments are essential for tracking the illness course of borderline personality disorder (BPD), marked by clinical instability. Quantitative language analysis has proven valuable for in-situ psychopathology studies. Here, we examine lexical features in repeated clinical interviews in relation to BPD treatment response.

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

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.

Rapid facial mimicry responses are preserved in youth with first presentation borderline personality disorder

BackgroundEmpathy is a complex and multifaceted construct comprising cognitive and affective components. Abnormal empathic responses are implicated in borderline personality disorder (BPD). Specifically, unconscious motor mimicry (a primitive component of affective empathy evident from infancy) is theorized to be heightened and to contribute to the heightened emotional contagion often seen in people with BPD. Yet, no study has directly tested whether abnormally heightened unconscious motor mimicry is associated with BPD features or whether this is present early in the course of BPD. MethodsIn the present study, facial electromyography was used to assess the rapid facial mimicry responses (a form of unconscious motor mimetic responding) of 32 outpatient youths (aged 15–25 years) with early stage BPD features and 47 demographically matched healthy control participants (HC). ResultsThe results showed no group differences in rapid facial mimetic responses to either positive (happy) or negative (angry) facial emotions. LimitationsCo-occurring psychopathology and the potential impact of state affect on rapid facial mimicry were considered and discussed. ConclusionsThese data indicate that there is no evidence for abnormally heightened rapid motor mimicry in youth early in the course of BPD, suggesting that rapid facial mimicry is preserved in this group. It is thus unlikely that abnormally heightened unconscious simulation contributes to heightened emotional contagion in youth with first presentation BPD. Future research should explore alternative mechanisms for this phenomenon and also whether abnormalities in motor mimetic responses are evident in later stages of the disorder.

Ovarian Hormones as a Source of Fluctuating Biological Vulnerability in Borderline Personality Disorder.

To examine the potential role of ovarian hormones in biological vulnerability to borderline personality disorder (BPD). The review focuses primarily on research examining the menstrual cycle as a source of short-term lability of BPD symptom expression, while discussing the currently understudied possibility of ovarian hormone influence in the developmental course of BPD. Several patterns of menstrual cycle effects on BPD symptoms and relevant features in non-clinical samples have been observed in empirical studies. Most symptoms demonstrated patterns consistent with perimenstrual exacerbation; however, timing varied between high and low arousal symptoms, potentially reflecting differing mechanisms. Symptoms are typically lowest around ovulation, with an exception for proactive aggression and some forms of impulsive behaviors. Preliminary evidence suggests ovarian hormones may exert strong effects on BPD symptom expression, and further research is warranted examining mechanisms and developing interventions. Recommendations for researchers and clinicians working with BPD are provided.

Number of Borderline Personality Disorder Criteria and Depression Predict Poor Functioning and Quality of Life in Outpatient Youth.

This study aimed to investigate which factors contribute to poor functioning and poor quality of life in youth (aged 15-25 years) with borderline personality disorder (BPD), and whether the number of BPD criteria might be an independent predictor of these outcomes. A sample of 499 help-seeking outpatient youth, aged 15-25 years, was assessed. Stepwise multiple regression analyses showed that the number of BPD criteria was the best predictor of poor functioning, followed by number of mental health visits in the past month, female sex, and a current diagnosis of depression. Current depression was the best predictor of Assessment of Quality of Life utility score, followed by the number of BPD criteria. These findings underscore the clinical significance of DSM-IV BPD features (even when subthreshold for a categorical diagnosis) in youth and their effects upon social and occupational functioning and quality of life early in the course of BPD.

Psychotic symptoms in borderline personality disorder: an update.

The purpose of this article is to review the most recent literature on psychotic symptoms in borderline personality disorder (BPD). Both auditory hallucinations and delusional ideation (especially paranoid delusions) are relatively common in individuals with BPD. It is still difficult to distinguish these and related phenomena in BPD from the corresponding experiences in psychotic disorders and schizophrenia, despite numerous attempts to do so. The terminology introduced to help with this effort has not been particularly useful. The presence of auditory hallucinations may affect the course of BPD negatively. Psychotic symptoms in BPD seem to be significantly related to the context (usually stressful events) and appear or intensify in response to situational crisis. The role of certain co-occurring disorders in increasing the risk of psychotic symptoms in BPD remains uncertain. Psychotic symptoms in BPD continue to be poorly understood. Further research should try to ascertain the relationships between hallucinations and delusions on one hand and the processing of trauma, emotion regulation, distress tolerance and interpersonal sensitivity on the other. Ultimately, such endeavor will contribute to developing more effective treatments for BPD.

Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies

BackgroundThis meta-analytic review is the first to synthesise findings from prospective research on the long-term course of borderline personality disorder in adult clinical populations. MethodsSystematic searches were conducted in Medline, PsycINFO, PsycArticles, PubMed and Scopus within the period 1990-2017. Inclusion criteria were: (1) adult BPD sample diagnosed by a validated, semi-structured interview; (2) at least two prospective assessments of outcomes; and (3) follow-up period ≥ 5 years. Quality of evidence was rated with the Systematic Assessment of Quality in Observational Research (SAQOR). Four outcomes were meta-analysed using mixed-effect methods: remission from BPD diagnosis, completed suicide, depressive symptoms, and functioning. Potential moderators regarding the natural course and the initial treatment received were studied. ResultsEleven studies met the inclusion criteria, with 837 participants from nine countries being followed. Between 50% and 70% of the BPD patients achieved remission in the long-term. Significant reductions in depression and functional impairment were also found. Mean suicide rate ranged from 2% to 5%. Younger age was associated with higher likelihood for remission. Being female was correlated with lower functional improvement. Despite some positive trends, there were no significant associations between treatment moderators and the long-term outcome. ConclusionsFindings suggest that the course of BPD is characterised by symptomatic amelioration and a slight functional improvement in the long-term. Age and gender modulate the long-term prognosis and should be considered to adapt treatment resources. Further research is required to draw robust conclusions on the long-term effects of psychotherapeutic interventions.

Dynamic associations between borderline personality disorder and stressful life events over five years in older adults.

The time course of borderline personality disorder (BPD) is far more variable than traditionally assumed. Shifting environmental conditions are theorized to account, at least in part, for fluctuations in symptom presentation over time. In the present study, we evaluated the reciprocal influences of stressful life events and borderline pathology in a representative community sample of 1,630 older adults assessed 3 times over 5 years. An autoregressive cross-lagged model revealed strong, but imperfect, stability in symptoms of BPD over the study time frame. After adjusting for this continuity in BPD, the prospective effect of life stress on borderline pathology was virtually nil, contrary to expectations. On the other hand, borderline pathology was prospectively related to subsequent dependent event (i.e., stressors to which individuals may have contributed), but not independent event (i.e., fateful stressors), exposure. This pattern of associations was consistent with a stress generation effect. We conclude that stressful life events do not substantially redirect the trajectory of BPD in older adults, possibly owing to inertia of borderline pathology at this developmental stage. Instead, symptoms of BPD seem to promote stress exposure, thereby setting the stage for continued social impairment and comorbid psychiatric problems. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The physiological orienting response in female adolescents with borderline personality disorder

BackgroundThe reflexive startle- and orienting-response have been widely studied in psychiatric disorders. Existing evidence in patients with borderline personality disorder (BPD) is mixed, and limited to adults. The present study addressed clinical correlates of the psychophysiological orienting response in adolescents with BPD. MethodsFemale adolescents (13–19 years) with BPD (n = 30), healthy controls (HC; n = 34), and psychiatric clinical controls (CC; n = 53) participated in the trial. Orienting response was induced using acoustic startle-probes (sinus tones) while heart rate (HR) and skin conductance (SCR) were continuously recorded. Besides clinical interviews, the assessment included self-reports on depressive symptoms, anxiety, dissociation and psychopathological distress. ResultsOn a group level, relative habituation of the HR-response (regression slope) significantly differed between groups (F(2,114) = 3.74, p = 0.027), with significant contrasts (p = 0.026, Sidak corrected) comparing CC (slope 0.04 ± 0.41) and BPD (slope 0.28 ± 0.40). On a dimensional level, relative HR habituation was significantly correlated with the number of BPD diagnostic criteria endorsed (r(117) = 0.183, p = 0.049) and symptoms of dissociation (r(116) = 0.193, p = 0.038), indicating that delayed HR habituation across probes was associated with greater BPD symptom severity. Analyses of SCR showed no significant findings. ConclusionFindings provide preliminary support for altered habituation of the HR orienting response in adolescent BPD, associated with BPD severity – in particular dissociative experiences. Dissociative experiences may alter the automatic defensive response early in the course of BPD, providing a potential pathway to exaggerated emotional responding in BPD.

Borderline personality pathology and physical health: The role of employment.

Borderline personality disorder (BPD) is associated with negative physical health outcomes. Clinical case studies suggest that employment status may buffer against the negative effects of BPD on physical health. The goal of the current study was to examine the interaction between BPD features and employment status in predicting subjective perceptions of physical health. We hypothesized that employment status would moderate the relationship between BPD features and physical health, such that individuals who are employed would exhibit a weaker negative relationship between BPD features and self- and informant ratings of physical health. We investigated this question using data from a community sample of 1,630 middle-aged to older adults participating in the St. Louis Personality and Aging Network, an ongoing study of personality, health, and aging. Results indicated that employment status and BPD features were significant predictors of both self- and informant ratings of physical health. Confirming our hypothesis, the interaction term contributed to a significant increase in the proportion of explained variance, suggesting that employment is associated with a weaker negative relationship between BPD features and physical health. These findings highlight the importance of examining occupational functioning in the long-term course of BPD and offer avenues for further research into moderators of the relationship between BPD features and physical health. (PsycINFO Database Record

Evaluation of a psychoeducational group intervention for family and friends of youth with borderline personality disorder

BackgroundDespite high levels of burden and distress among families with a member who has borderline personality disorder (BPD), only two BPD specific family psychoeducation groups have been empirically evaluated. Neither of these is designed specifically for the family and friends of young people who are presenting early in the course of BPD. This study aimed to evaluate Making Sense of Borderline Personality Disorder (MS-BPD), a three-session, developmentally tailored, manualised psychoeducational group for the family and friends of youth with BPD features.MethodsThe study employed a pre- and post-intervention, repeated measures design. Twenty-three participants completed self-report measures assessing for family burden, psychological distress, and knowledge about personality disorder. Demographic data were collected for the group participants and for their associated young person with BPD. Paired-samples t-tests were conducted to evaluate the effect of the MS-BPD intervention on participants’ burden, distress and personality disorder knowledge.ResultsAt the completion of session three (day 15), group participants reported significantly decreased subjective burden and increased personality disorder knowledge. Objective burden and distress remained unchanged.ConclusionsFamily and friends of young people with BPD features experienced subjective, but not objective, benefit from attending a brief group-based psychoeducation intervention. Longer follow-up is likely to be required to detect behavioural change. The current findings support proceeding to a randomised controlled trial of MS-BPD.

Long-Term Course of Borderline Personality Disorder: A Prospective 10-Year Follow-Up Study

The aim of this prospective study was to expand previously reported evidence on the 10-year clinical and functional course of borderline personality disorder (BPD) in a Spanish sample. Participants diagnosed with BPD were assessed at baseline and at 10-year follow-up to evaluate BPD symptomatology and other relevant clinical measures, suicidal behavior, dimensional personality traits, Axis I and II comorbidity, use of mental health resources, and psychosocial functioning. At the 10-year follow up, significant improvements were observed on BPD domains, suicidal behavior, and other clinical measures. Neuroticism, impulsiveness, and aggression-hostility features trended toward normalization, whereas activity and sociability were impaired over time. Comorbidity with Axis I and personality disorders remained high. Social functioning and occupational functioning were largely unchanged. These findings confirm the tendency toward a symptomatic remission of BPD over the long term with regard to symptom criteria and characteristic dimensional traits. However, psychosocial functioning remains impaired.

Long-Term Course of Borderline Personality Disorder.

Information concerning the longitudinal course of Borderline Personality Disorder (BPD) derives mainly from (a) long-term (10 to 25 year) retrospective follow-up studies, primarily those conducted during the 1980s/1990s, (b) brief (1 to 3 year) follow-up studies of recent randomized controlled trials (RCTs) of several different treatment approaches, and (c) prospective follow-up studies. The patients contacted in the retrospective studies had been treated mostly by psychoanalytically informed approaches or supportive. Though there was a significant suicide rate of 3 to 9%, about two-thirds of the BPD patients eventually achieved a global assessment score in the 60s or beyond. BPD represents a heterogeneous group of patients, whose outcome is a function of many variables, including personality traits (paranoid and narcissistic conducing to less favorable outcomes), cultural differences, socio-economic level, intelligence level, gender, and age of onset. The RCT studies focused on amelioration of the symptom components of BPD, especially tendencies to self-injury and suicide. The currently favored treatment methods showed in a large percentage of patients, a lessening of these self-destructive behaviors after a year or two of treatment. The time spans were too brief to allow assessment of improvement in key life areas (attainment of self-sufficiency in work, widening of the circle of friends, and success in forming satisfactory intimate partnerships). The prospective studies are based on reassessments at regular intervals of BPD patients and a control group with other personality disorders. Over the past 16 years the BPD patients, compared with controls, were slower to achieve remission, and more apt to show cognitive peculiarities initially-though they showed appreciable improvement over time. The "recovered" BPD patients, compared with the non-recovered patients, showed twice the likelihood of achieving a successful intimate relationship. At 16 years the McLean study has shown results similar (though scientifically more precise) to those of the old retrospective studies. The studies do not demonstrate the efficacy of one or another treatment approach, since, in long-term follow-up, psychotherapy, albeit essential, becomes one of a myriad of influences affecting outcome. There is general agreement that BPD patients who have experienced severe early trauma (including incest) are at greater risk for a poor outcome-as are those with prominent antisocial traits (more common in BPD males). The personality trait of agreeableness was associated with greater likelihood of favorable outcome.