It Takes a Borderline Village

Since its introduction in DSM-III in 1980, a great deal of progress has been made in our understanding of borderline personality disorder (BPD), but this did not occur without enormous effort. Even almost 10 years later, APA convened a task force on BPD, and the consensus in the 1989 report of that task force was discouraging: treatment was difficult, severe counter-transference problems were common, and treatment outcome was variable. But only two years later, the American Journal of Psychiatry (AJP) published the Practice Guideline for the Treatment of Patients With Borderline Personality Disorder, which recommended psychotherapy as the core, evidence-based treatment for BPD, accompanied by symptom-targeted adjunctive pharmacotherapy when indicated.

The evidence base for this practice guideline consisted primarily of studies by Linehan and colleagues on the use of dialectical behavior therapy (DBT) and the work of Bateman and Fonagy on mentalization-based therapy (MBT). Since then, randomized, controlled trials have been published by other research groups, reporting the effectiveness of a number of different types of psychotherapy for the treatment of patients with BPD.

The growing literature on treatment of BPD has been matched by great progress in research on the neurobiology, genetic risk factors, and long-term course of BPD, and this new knowledge informs our treatment and greatly facilitates efforts to destigmatize BPD. As I wrote in a 2009 editorial in AJP, the behavior of patients with BPD was too often “seen as willfully oppositional, and borderline personality patients were spoken of as dreaded pariahs.” But we now know, for example, that mistrustful behavior is likely to be illness driven, related to heritable emotional hyperreactivity and inadequate cortico-limbic capacity to downregulate emotions, greatly compromising the ability to develop stable interpersonal relationships. (This biological vulnerability is all too often accompanied by real experiences of neglect or trauma in early development, but not invariably so.) We have also learned from studies like the 15-year NIMH-funded Collaborative Longitudinal Personality Disorder Study that BPD does not represent a “life sentence,” but, rather, that patients with this disorder get better over time.

Steadily working to get this more optimistic message out are advocacy groups and family groups that provide invaluable psychoeducation and patient and family support, such as the National Education Alliance for BPD (NEABPD) and the Treatment and Research Advancements National Association for Personality Disorder. (Check out their Web sites for rich resources for patients and families.) The National Alliance on Mental Illness (NAMI) has designated BPD as a high-priority condition, and through the efforts of NAMI and NEABPD, the House of Representatives unanimously passed House Resolution 1005 in April 2008 designating May as Borderline Personality Disorder Awareness Month “as a means of educating our Nation about this disorder, the needs of those suffering from it, and its consequences. …”

While there is much work still to be done, the cumulative efforts of clinicians, researchers, advocates, families, and, of course, patients themselves are paying off. I had the pleasure of making a presentation at an educational event on BPD in October in New York sponsored by NEABPD; other presenters included former APA President Herb Pardes, New York State Commissioner of Mental Health Mike Hogan, NIMH researcher Bruce Cuthbert, and Columbia University researcher Barbara Stanley, along with Amanda Wang, a remarkable individual who spoke about her own struggles with BPD and her road to recovery. And just a few weeks later, in November, the Substance Abuse and Mental Health Services Administration (SAMHSA) held an all-day meeting cosponsored by NAMI and NEABPD and titled “Federal Partners Meeting on the Borderline Personality Disorder.” This milestone event included presentations by Pam Hyde, administrator of SAMHSA; Kathryn Power, director of the Center for Mental Health Services; Mike Fitzpatrick, executive director of NAMI; and Perry Hoffman, president of NEABPD. Other speakers included John Gunderson, Marsha Linehan, Ken Duckworth (medical director of NAMI), Blaise Aguirre (medical director of the Adolescent DBT Center at McLean Hospital); Jim Breiling (NIMH), and me; the afternoon “Federal Partners Think Tank on BPD” was cochaired by Tom Insel, director of NIMH, and Kathryn Power. As Power stated in her remarks earlier in the day, “It truly ‘takes a village’ to transform individuals’ lives. When SAMHSA submitted its ‘Report to Congress on Borderline Personality Disorder’ last May, it reflected our commitment to work closely with the NEABPD and NAMI, our federal partners, individuals in recovery, and our champions in Congress. … Together, we share a commitment to increase knowledge about borderline personality disorder, provide education to individuals and families, expand the availability of evidence-based treatments, and promote resilience and recovery.”

Kathryn Power raised the following question about patients with BPD: “Are they isolated because they are suffering, or are they suffering because they have been isolated …?” I would say it’s both, and our collective challenge is to intensify the good momentum of progress now in motion. More clinicians need to be trained to provide evidence-based treatment, more research needs to be funded, and more people need to have opportunities to learn about the far more informed and optimistic state of our knowledge about BPD. One such opportunity will be at our 2012 annual meeting in Philadelphia, where a number of sessions on BPD will be on the program, including an invited symposium chaired by Andy Skodol titled “Integrated Approaches to the Care of Patients With Borderline Personality Disorder” and a Frontiers of Science presentation on BPD by Marsha Linehan. Plan to attend and spread the word!