PROSPECTIVE STUDIES OF OUTCOME Understanding Mechanisms of Change in Patients with Borderline Personality Disorder

The authors propose a conceptual model of recovery from BPD that takes into account empiric findings regarding the dynamic relationships between severity of BPD symptoms, age, impulsivity, and duration of a healing relationship. The model assumes that each factor related to the course of BPD essentially lies on a continuum and interacts with the remaining important factors. The model also preserves the relative relationships, with age and impulsivity being primarily important and the duration of a healing relationship being independent but overall of less importance in modifying the course of illness. (Having said this, however, modifying the presence of a healing relationship may be more accessible for therapists.) By 7 to 10 years' follow-up, half of patients with BPD will be characterized as remitted. Efforts to keep these patients alive through the early course of the disorder will see many patients through to the resolution of the disorder. Impulsivity is a primary element of the disorder that predicts the course of BPD, with impulsivity becoming less as patients age. Efforts to modify the levels of impulsivity, such as rehabilitation for substance-abuse disorder, pharmacologic interventions, and cognitive-behavioral therapies to reduce impulsivity, may affect the course of the disorder. Exposure to an intimate relationship, such as a successful marriage, also may impact the course by allowing the person to be involved in a healing relationship. Additional studies are needed on the role of couple and marital interventions with BPD patients because the development of successful relationships may modify the course of the disorder. This model of change in BPD is conceptually heuristic and accounts for the complex interplay of factors that modify the course of BPD but accounts for the empiric findings to date. This model is also presented to assist clinicians in understanding and conceptualizing the primary features affecting recovery for these patients. As new findings become available, this model should be modified to reflect the nature of those findings and extend the understanding of the course of BPD and the factors that modify that course of illness.