A posting by Jim Breiling, Ph.D.
June 27, 2012
What does recovery mean to borderline personality disorder service users? How has treatment helped? What needs more treatment?
C. Katsakou of the Unit for Social and Community Psychiatry at Queen Mary University of London, United Kingdom, and six co-authors, including a BPD service user, addressed the above questions in interviews of 48 service users for BPD. Their data and results are reported in a May paper in PLoS One (see citation and abstract immediately below this text, followed by instructions on accessing a free copy of the full paper).
1. This paper can be meaningful because an array of research evidence has overturned the clinical belief that BPD is a chronic disorder, unresponsive to treatment. Symptom remission is the rule (albeit with challenging exceptions).
2. The study sample of 48 borderline personality disorder service users was drawn from two specialty services inEast London. To be considered for the study, service users had to have a diagnosis of borderline personality disorder, have engaged (past and/or present) in self-harming behavior and participated in treatment for a minimum of four months. The authors had self-harming as an inclusion criteria in a quest for a homogeneous sample; also, persons who have experienced more serve BPD symptoms more frequently use treatment for BPD; and, based on their c1linical experience, BPD service users who self-harm would have a lower frequency of Axis I disorders.
The confidence is uncertain about the extent to which the study findings can be generalized beyond the BPD service users inEast Londonand to those who do not meet criteria for inclusion in the study. And since the study authors used a semi-structured interview rather than preset questions, precise replication of their method for obtaining data is not possible, with unknown implications for the nature of the results. Thus, as with almost all initial results from searches, research (replication) is needed to determine the extent to which the initial search findings are durable and generalize.
As is typical in clinical settings in this country, most of the sample was female, white and unemployed. A majority were living alone. The mean age was early middle age (36).
A pleasant surprise and unwelcome contrast to mostUSclinical services was that about two-thirds of the study sample had received a treatment for which there was strong support in the research literature, i.e., an evidence-based treatment (DBT and Mentalization). Three-fourths had completed treatment.
Most of the BPD service users recognized progress in treatment while also identifying needs for more progress in accepting themselves and building self-confidence, relationships, controlling their emotions (mood swings) and self-harming, suicidality and other symptoms. Of particular note:
“Participants believed that having more meaningful activities in their lives is particularly important.”
“They also wanted to work towards finding a job and making progress in their career, as this makes them feel more competent and normal.”
As for recovery, there was a general rejection of a dichotomy between having BPD and being recovered from BOD.
“… (t)hey could not imagine not having some difficulties in dealing with their emotions and lives. Thinking that they are recovered following … a dichotomous definition was also seen as dangerous, as it could be unrealistic, indicate a lack of acceptance of their problems, and lead to not monitoring themselves and therefore relapsing.”
BPD service users wanted treatment that was broader (and more responsive to their perception of needs) than what DBT and Mentalization offered. In this, Marsha Linehan was also a leader. Early in her work on DBT, Dr. Linehan placed DBT as the initial treatment (because of its focus on preventing suicide, which if successful would eliminate the need for treatment) in a sequence of different treatment approaches. The treatment evaluation data that has appeared subsequently fully support this view for all of the BPD treatment models.
PLoS One. 2012;7(5):e36517. Epub 2012 May 17.
Recovery in Borderline Personality Disorder (BPD): A Qualitative Study of Service Users’ Perspectives.
Katsakou C, Marougka S, Barnicot K, Savill M, White H, Lockwood K, Priebe S.
Unit for Social and Community Psychiatry, Queen Mary University of London,London,United Kingdom.
Symptom improvement in Borderline Personality Disorder (BPD) is more common than previously hypothesized. However, it remains unclear whether it reflects service users’ personal goals of recovery. The present study aimed to explore what service users with BPD view as recovery.
48 service users were recruited from secondary mental health services and their views on their personal goals and the meaning of recovery were explored in in-depth semi-structured interviews. The study drew on grounded theory and thematic analysis.
Service users believed that recovery involved developing self-acceptance and self-confidence, gaining control over emotions, improving relationships, employment, and making progress in symptoms like suicidality and self-harming. They felt that psychotherapies for BPD often had an extreme focus on specific areas, like self-harming or relationships, and that some of their goals were neglected. Although full recovery was seen as a distant goal, interviewees felt that they could learn how to deal with their problems in more effective ways and make meaningful progress in their lives.
Specialist therapies for BPD explicitly address some of the recovery goals that are important to service users, whereas other goals are only indirectly or poorly addressed. Professionals might need to work with service users towards devising comprehensive individualized case formulations, including all treatment targets that are important to service users, their priorities, and long-term plans on how their targets might be met and which services might be involved.
PMID: 22615776 [PubMed – in process] PMCID: PMC3355153 Free PMC Article
The full paper is available free. See below for the steps to accessing the full paper:
1. Go to Pub Med (NIH’s computer program for searching the world’s biomedical research journals; available to all to use 27/7 without charge — US taxpayer dollars at work; use it for other searches):
2. For the search term, enter the first author’s last name and initial of first name: Katsakou C
3. As of today: The recovery paper will be the first of 18 papers for which Katsakou is one of the authors. Click on the title.
4. The journal citation and abstract will appear. In the upper right corner of this web page twill be two options for free access to the entire paper: PLoS one AND PubMedCentral. Click on your choice, and “there she be” — the entire paper.
Top Psychiatry Journals
Recognize BPD Research
In last month’s (the May) issue of prestigious and highly selective American Journal of Psychiatry, two of that issue’s eight research papers reported borderline personality disorder research, and they were in the lead positions for research reports. First was a report by Mary Zanarini and three colleagues at Harvard’s McLean Hospital with results from her NIMH-supported prospective follow-up to 16 years in which patients with borderline personality disorder were compared to patients with other personality disorders for remission from their disorders and for recovery. This report was also one of four selected for editorial attention, with the editorial about this study in the lead position in the editorial section of the journal.
The citation and abstract of the paper can be accessed at
A PDF of the entire editorial can be accessed at
The other borderline personality disorder research paper in the May issue of the American Journal of Psychiatry comes from Paul Soloff’s NIMH supported research. The paper reported prospective predictors of suicidal behavior by borderline personality disorder patients to 6 years by Paul Soloff and a colleague at the University of Pittsburgh. This paper was also the only one in this issue to be recognized as of such clinical importance as to warrant designation for continuing medical education (CME) credit.
The citation and abstract for this paper can be accessed at
In the current (June) issue of The American Journal of Psychiatry, one of the only eight research papers in this issue was a report of a randomized clinical trial (RCT) — the Gold Standard — in which dialectical behavior therapy (DBT) was compared to general psychiatric management during one year of intervention and then for a two-year follow-up. Shelley McMain at the University of Toronto and four Canadian colleagues were the authors of this paper. This was also one of four research papers selected for editorial attention.
The citation and abstract for this research report can be accessed at
A PDF with the entire editorial related to this research report can be accessed at
This month (June) The Archives of General Psychiatry, the other premier psychiatric journal, published on-line a neuroscience comparison of brain network connectivity during pain processing for patients with borderline personality disorder and normal comparison subjects. Rosemarie Kluetsch in Germany and nine colleagues were responsible for this report.
The citation and abstract for as well as the entire paper can be accessed at
The clinical research reports concur in finding significant symptom improvement from various treatments but that symptom elimination and recovery remain a challenge for many with borderline personality disorders. New applications of existing treatments or new treatments are needed to enable enduring symptom remission and attainment of recovery with satisfying interpersonal relationships and attainment of vocational success. See below for relevant quotes from the abstracts of the three clinical study reports:
Zanarini, et al —
“Conclusions: Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.”
Soloff and Chiappetta —
“Conclusions: Risk factors predictive of suicide attempt change over time. Acute stressors such as major depressive disorder were predictive only in the short term (12 months), while poor psychosocial functioning had persistent and long-term effects on suicide risk. Half of borderline patients have poor psychosocial outcomes despite symptomatic improvement. A social and vocational rehabilitation model of treatment is needed to decrease suicide risk and optimize long-term outcomes.”
McMain, et al:
“Conclusions: One year of either dialectical behavior therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.”