New Knowledge and New Conceptions

July 1, 2004
John G. Gunderson, MD

Volume 21, Issue 8

Our evolving understanding of borderline personality disorder and its treatment includes the surprising evidence that this disorder has more significant genetic determinants and many patients have a far better prognosis than had previously been thought. Treatment approaches have also become less intensive and more diverse and specific. This is a disorder that, despite the considerable gains, remains one of psychiatry's most vexsome problems and one of society's major health care priorities.

Our evolving understanding of borderline personality disorder (BPD) and its treatment is reflected in each of the contributions to this Special Report of Psychiatric Times. This evolution includes the surprising evidence that this disorder has more significant genetic determinants and many patients have a far better prognosis than had previously been thought. John M. Oldham, M.D., describes newer conceptions of borderline psychopathology as the combination of different phenotypes (e.g., affective instability and impulsive aggression) that have neurobiological correlates, and he indicates that such considerations suggest that a dimensional model has advantages compared to the traditional categorical approach to diagnosis.

The evolution of our knowledge about treatment of BPD is equally dramatic. From an earlier conception of treatment that rested largely on long-term, intensive psychoanalytic therapy and long-term hospitalization, current treatments are less intensive, more diverse and decidedly more specific to borderline psychopathology. The development of a form of behavioral therapy--dialectical behavior therapy (DBT)--which received empirical validation a decade ago, was instrumental in bringing about these changes.

Dialectical behavior therapy departs from usual behavioral therapy insofar as its developer, Marsha Linehan, Ph.D., discovered that patients with BPD require validation and acceptance before change is possible. As described by Anthony W. Bateman, M.A., FRCPsych, psychoanalytic therapies are now receiving a much-needed boost from more recent research. Bateman and Peter Fonagy, Ph.D., FBA, developed a therapy--mentalization-based treatment (MBT)--which was found to be effective with patients with BPD. Readers who are not familiar with MBT will receive a valuable introduction in Bateman's article to a treatment that seems destined to soon take its place beside DBT as an empirically based therapy for BPD. Also of note, the form of psychotherapy long championed by the psychoanalytic leader Otto F. Kernberg, M.D.--now refined, manualized and named transference-focused psychotherapy (TFP)--is going through empirical testing. The efficacy of MBT and potentially of TFP for patients with BPD offers a significant opportunity for psychoanalysis to regain a place within modern psychiatry.

However, it would be unwise to suggest that the competing claims for either behavioral or psychoanalytic models should receive more attention than the claims for supportive therapy as described by David J. Hellerstein, M.D., and colleagues. The importance of support is clearly evident in that both behavioral (DBT) and psychoanalytic (MBT or TFP) approaches needed significant modifications of standard practices to include more supportive interventions before they could be made useful for patients with BPD. The importance of supportive interventions is also evident in the data from longitudinal studies that document the potential for rapid and early remissions from effective case management. Not surprisingly, as Hellerstein and co-authors describe, supportive therapy also requires modifications to be suitable for this patient group.

The article by Paul S. Links, M.D., FRCPC, and colleagues is a clinically wise discussion of assessing and managing the recurrent suicide risks that characterize patients with BPD. Of particular note may be their admonition about the use of hospitals as part of the safety management of these patients. As a reaction against the failures of long-term hospitalization, many psychiatrists have tried too hard to avoid hospitalizing their patients with BPD. Links and colleagues rightly note that modern short-term hospitalizations have few of the regressive dangers that previously existed.

Together, these articles provide a useful update on new knowledge and new conceptions about BPD, a disorder that, despite the considerable gains, remains one of psychiatry's most vexsome problems and one of society's major health care priorities. Increased public awareness, support by the National Institute of Mental Health and foundations for research, and the prospect of overdue investments in drug trials by the pharmaceutical industry all promise that the current surge of knowledge will continue to grow.

It is with great appreciation that Psychiatric Times acknowledges Dr. Gunderson for his work in planning and reviewing this special report. Dr. Gunderson is professor of psychiatry at Harvard Medical School and is director of the Center for Treatment and Research on Borderline Personality Disorder at McLean Hospital.