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Interpersonal Relationships Predict Course of BPD

The quality of their relationships with children may help predict how patients with borderline personality disorder will fare in treatment. This is in line with reports indicating that for some patients motherhood leads to positive self-esteem, while others can be immobilized by the difficulties of childrearing.

The quality of a patient's current interpersonal relationships and history of childhood trauma are factors that can aid clinicians in rendering a prognosis for treatment of borderline personality disorder (BPD).

That was a new finding from the study "Predictors of Two-year Outcome for Patients With Borderline Personality Disorder" published in the May American Journal of Psychiatry.

Somewhat more predictably, the longitudinal follow-up of 161 patients with BPD found that the strongest predictor of two-year outcome was severity of baseline psychopathology as measured by the number of BPD diagnostic criteria and functional disability.

But the finding that an assessment of interpersonal stability can aid in the prediction of outcome was something of a surprise. "Interpersonal relationships have not been examined very often as prognostic variables," lead author John Gunderson, M.D., told Psychiatric News. "In our study, we looked at interpersonal relations alongside the other two factors—impulsivity and affective instability. These other two factors have often been looked at in prior research.

"The overall quality of the borderline patients' interpersonal relationships proved to be a stronger predictor of course than either their affective instability or impulsivity," said Gunderson, a professor of psychiatry at Harvard Medical School and director of the Center for Treatment and Research on Borderline Personality Disorder at McLean Hospital. "That interpersonal relations have predictive value is clinically useful and adds to prior research. This means that clinicians should recognize that their patients with the most chaotic, stormy, and frequent interpersonal disturbances are not likely to get well soon."

Impulsivity Data Surprising

Gunderson added that the finding that impulsivity was not predictive was surprising, since it had emerged as a solid predictor in other studies. "We don't really understand why it wasn't here," he said. "Our sample was pretty representative, and our assessments were reliable and used standard measures. Perhaps longer-term follow-up will tell us more."

In the study, 160 patients were recruited from four clinical sites of the Collaborative Longitudinal Personality Disorders Study. Patients were assessed at baseline and at six, 12, and 24 months with the Structured Clinical Interview for DSM-IV Axis I disorders; the Diagnostic Interview for DSM-IV Personality Disorders, a modified version of that instrument; the Longitudinal Interval Follow-Up Evaluation; and the Childhood Experiences Questionnaire–Revised.

Three Categories Assessed

The patients were assessed for a range of variables, grouped into three categories—psychiatric history, developmental experiences, and presenting phemonenology.

Psychiatric history variables found to be predictive were length of previous hospitalizations and early age of psychiatric contact. Developmental experiences predictive of poor outcome included childhood abuse, parental underinvolvement, being a victim of father-daughter incest, parental divorce, parental brutality, childhood separations or losses, and disturbed maternal relationships.

Predictor variables within presenting phenomenology traits were of three subtypes: severity, comorbidity, and personality. Severity variables previously reported to predict poor outcome include having low Global Assessment Scale scores, meeting a greater number of bipolar disorder criteria, and presenting a greater number of Axis II diagnoses at follow-up.

Comorbidity variables found to be predictive of poor outcome include substance abuse and depression or "dysphoria." Comorbid personality predictor variables of poor outcome include those related to schizotypal, antisocial, and paranoid personality disorders. Better outcome was related to comorbid obsessive-compulsive personality disorder.

Personality trait variables that predicted outcome were impulsivity and affective instability.

Two-year outcome was assessed according to measures of global functioning and number of borderline personality disorder criteria.

The clearest and strongest finding from the study was that the greater the severity level of dysfunction and psychopathology at baseline, the worse the outcome. yet Gunderson drew attention to the fact that the study did not yield overwhelmingly conclusive results for any of the predictors.

"A rather sobering message is that none of the predictors is very strong," he told Psychiatric News. "The heterogeneous and often quite positive course of borderline patients remains hard to predict with confidence."

Nevertheless, the relevance of the quality and stability of current interpersonal relationships is a finding that will aid clinicians in determining prognosis and treatment. Related to this was a finding that among BPD patients who are parents, the quality of relationships with their children was also predictive.

This is consistent with clinical reports that some patients with BPD find motherhood a source of positive self-esteem and security, whereas others can be immobilized by the conflicts related to nurturing or disciplining their children, according to the report.

"Clinicians have often been exposed to borderline patients who found the stress of mothering overwhelming," Gunderson said. "Whenever they felt angry at their child, they felt they were bad and became self-destructive. This study sheds light on the other side of this. Many borderline patients have found the mothering experience a source of stability and self-esteem. They are less apt to reappear in treatment settings. knowing this has made me more circumspect about advising women with borderline personality disorder whether to have children or not."

"Predictors of 2-Year Outcome for Patients With Borderline Personality Disorder" is posted at <http://ajp.psychiatryonline.org/cgi/content/full/163/5/822>.

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