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Can I Recover from Borderline Personality Disorder? An introduction to treatment outcome measures.

Updated: Aug 30, 2019

A question I hear at our weekly support group time and time again is some variation on the following: Can BPD be cured? Will I get better? Will treatment work?


Measuring Recovery from Mental Illness


Symptom Measurement

It depends on what you mean by "work". In clinical psychology, we call this the outcome measure. The outcome measure defines what is expected to change with treatment, how it can be measured, and how it relates to the underlying construct. For example: studies evaluating treatments for BPD use symptoms of BPD as their outcome measure. Symptoms of BPD are expected to decrease with treatment, can be measured by checklists or interviews, and are theorized to represent the underlying construct of BPD.



Functional Measurement

More recently, researchers have argued for the importance of including other measures of treatment success: quality of life (such as work or school involvement, relationship satisfaction, cognitive functioning) and qualitative interviews with the patient about their experience of treatment. These measures add important nuance because teatment often decreases a few symptoms of BPD - perhaps meaning a patient no longer meets criteria for diagnosis - but the patient is still experiencing significant problems in their relationships, work life, or subjective well-being.



Note: CREST.BD has developed a self-assessment tool for quality of life in patients with bipolar disorder. The tool is highly relevant to patients with BPD due to its holistic nature; assessing 12-14 (depending on school and/or work participation) domains of functioning. Take the quiz here, and access the Wellness Centre to address domains you're struggling with.

To review: recovery from BPD can be measured by symptom checklists, objective quality of life, and subjective experience of well-being. So what does a cure look like for you? Does it mean reaching a score of 0 on a symptom checklist, obtaining a similar quality of life to your peers, or something different?


Remission, Recovery, and Relapse


What is Recovery?

For Zanarini and colleagues at McLean Hospital, good recovery from BPD was defined as:


1. Remission - no longer meeting criteria for BPD (fewer than 5 symptoms) for two years

2. Good social functioning: one emotionally-sustaining and long-term relationship with a friend or partner

3. Full-time work or school involvement

4. A score of 61/90 on the Global Assessment of Functioning


Excellent recovery was defined as:

1. Remission - no longer meeting criteria for BPD (fewer than 5 symptoms) for two years

2. Good social functioning: one meaningful and long-term relationship with a friend or partner

3. Full-time work or school involvement

4. No comorbidity - the presence of another psychiatric disorder

5. A score of 71/90 on the Global Assessment of Functioning


Remission Versus Recovery

These definitions of recovery are important because they acknowledges issues with only measuring symptoms of BPD as an indicator of recovery: the fact that symptoms of BPD like suicidal thoughts and behaviours, self-injury, or relationship instability can be debilitating by themselves; returning to work after recovery can be a lengthy process that influences well-being; and other disorders like depression, anxiety, or trauma disorders might emerge during or after treatment.


Over the course of the McLean study, 59% of patients had achieved good recovery and 39% had achieved excellent recovery by the 20-year follow-up. This number is lower than the often cited 76% observed by the same researchers in 2003. This study measured simple remission - meeting fewer than 5 symptoms of BPD - rather than recovery.


So - how is excellent recovery achieved?


Treatment


Treatment Facilitates Recovery


During the 20-year follow-up period, patients received non-intensive treatment-as-usual (TAU) in outpatient settings: 90% were in individual therapy and taking medication when the study began, and 70% were engaged in each of these treatments at each wave of follow-up. Thus, this study does not suggest that BPD remits on its own; that the majority of patients were receiving treatment speaks to the importance of access to therapeutic services in the facilitation of recovery from BPD.


Improper Treatment Can Disrupt Recovery


Treatment factors that worsen BPD symptoms include frequent changes between care providers or inconsistent care, frequent long-term hospitalizations, and inconsistent medication use. Finch and colleagues published an article this year systematically analyzing TAU for patients with BPD across 16 studies. They found TAU varied between studies, and it was unclear what TAU entailed. A qualitative study on recovery in 48 patients with BPD found half had received dialectical behaviour therapy (DBT; 23 patients) while the other 25 patients received mentalization-based therapy (MBT; 8 patients), other psychological therapy (6 patients), or generic services (11 patients).


Implementing Effective Treatment


A stepped-care model appears to be a good fit for patients with BPD due to vast differences in symptom presentation and functionality. Stepped-care models are evidence-based hierarchies of care that match treatment to a patient's needs, resulting in less burden on crisis services and shorter wait times. Barriers to implementing a stepped-care model for patients with BPD include both individual and organizational factors:


Individual Factors Affecting Treatment Implementation

1. Lack of knowledge about BPD and its treatment (such as responding to a suicide attempt with a long-term hospitalization)

2. Lack of training in treating BPD (such as DBT training, responding to suicidal ideation or self-harm, fear of abandonment, or interpersonal difficulties that can negatively impact treatment)

3. Stigmatizing attitudes about patients with personality disorders


Organizational Factors Affecting Treatment Implementation

1. Lack of support from managers due to a belief that patients with personality disorders must be seen by specialist care providers

2. Conflicting governance policies regarding treatment of patients with personality disorders

3. Resistance to change within organizational culture resulting in inadequate resource allocation


What Predicts Recovery?

In contrast to traditional models of childhood adversity and severity of BPD symptoms predicting recovery, Zanarini and colleagues found childhood and adult vocational functioning were the strongest predictors of excellent recovery.


“Looking at these results in another way, achieving an excellent recovery is more about who you are and not what other people have done to you or failed to do for you.”

Treatment should focus on the ability of patients with BPD to function well in work and maintain resiliency in the face of adversity. Or, as Marsha Linehan and DBT puts it: Pain is unavoidable. Suffering is optional.


Increasing resiliency, competence, and social functioning in patients with BPD is key to achieving excellent recovery.


How do you measure your recovery?


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