Borderline Personality Disorder,  Mentalizing

It’s time to reject the notion that people with personality disorders are beyond help

It’s time to reject the notion that people with personality disorders are beyond help, writes Peter Aldhous
FENELLA Lemonsky was 15 when her life disintegrated. She had never been a happy child, but things went from bad to worse in adolescence. Her family had relocated from South Africa to London a few years earlier and she found it impossible to make friends. “I was having mood problems, I was binge-eating and I didn’t know what was happening to me,” Lemonsky recalls. “I would overdose and go to Accident and Emergency. Eventually, I spent time in various psychiatric hospitals, but they didn’t know how to treat me.”

Lemonsky had to wait until her late twenties even to be given a name for the condition that left every aspect of her life in disarray. Then, after one of her suicide attempts came perilously close to succeeding, a concerned doctor got her an appointment with Anthony Bateman at St Ann’s Hospital in London.

Bateman’s unit specialises in treating personality disorders, but Lemonsky didn’t realise that until, sitting in his office, she pleaded for an explanation of her problems. “He said: ‘It’s borderline personality disorder.’ I said: ‘Is it treatable?’ He said: ‘Yes.’”

This simple yet optimistic exchange will surprise many people who have been given the same diagnosis. It may even surprise some psychiatrists. Personality disorders revolve around difficulties interacting with other people. They can be extremely debilitating to those with the condition and those around them, and have been thought to be lifelong afflictions. Borderline personality disorder, in particular, has a terrible reputation, summed up on a cover of Time magazine as “The disorder that doctors fear most.” Even the current edition of psychiatry’s handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), perpetuates the gloom by describing personality disorders as “stable and enduring”.

“It turns out that it’s not true,” says John Oldham, a specialist in personality disorders at Baylor College of Medicine in Houston, Texas, and president of the American Psychiatric Association, which publishes the DSM. For despairing families, the encouraging news is that the problems of people with borderline personality disorder subside with age. Recent clinical trials have also shown that specialised psychotherapy can significantly improve their lives. Still, a lingering “untreatable” stigma, combined with the difficulty of securing funding for therapy, means that relatively few people with the condition get the help they need.

The encouraging results for borderline personality have kindled hope that other forms of personality disorder? – which are collectively more common but poorly studied? – might also be less ingrained and more amenable to treatment than thought.

Psychiatrists currently recognise 10 personality disorders, classified into three “clusters”? – though the constellation of conditions is mired in diagnostic confusion (see “What’s in a name?”, page 48 ). The disorders manifest in diverse ways, from the callous disregard of others typical of those with antisocial personality disorder?- many of whom pursue a life of crime?- to the extreme social anxiety of people with avoidant personality disorder. Problems interacting with others are the common thread. “You can’t have a personality disorder on a desert island,” observes Conor Duggan, a forensic psychiatrist at the University of Nottingham in the UK.

Borderline personality disorder, which is characterised by extreme emotional instability, is the best studied because the people that have it are aware something is badly wrong and tend to seek help. Anyone familiar with the condition knows that “borderline” doesn’t mean that people with this diagnosis are close to the boundary between mental health and mental illness. Far from it: the disorder got its name because it seemed to combine the distress of neurosis with some of the delusions of psychosis.

At the core of the disorder lies an inability to form stable relationships. People with borderline personality have an almost paranoid fear of abandonment, which often becomes a self-fulfilling prophecy. Friends may be idolised one day only to be despised the next after a perceived slight. Angry outbursts are frequent, and people who try to help often bear the brunt.

“These are patients who don’t trust you. They are highly vigilant and quick to misinterpret things,” says Oldham. “A lot of healthcare workers don’t understand that it’s part of the pathology and take it personally.”

Road to recovery

The first study, led by Mary Zanarini of the McLean Hospital in Belmont, Massachusetts, reported last year that 86 per cent of 249 patients had improved to the point that they no longer met diagnostic criteria for borderline personality for at least four years within the 10 years of follow up (American Journal of Psychiatry, vol 167, p 663).

This result was no fluke: in April this year a second study, which set a higher bar for judging remission, reported that 85 per cent of 111 patients had remitted for at least a year over a 10-year period (Archives of General Psychiatry, vol 68, p 827).

“I’ve been immersed with these patients and I didn’t anticipate it,” says John Gunderson, also at the McLean Hospital and one of the leaders of the second study. He says that psychiatrists simply failed to realise that many people who stopped turning up for therapy were actually getting better.

Given the suffering of people with borderline personality and their families, finding ways to accelerate recovery is a top priority. Although some progress has been made in understanding the condition’s biological basis (see Inside the borderline mind, page 47), the pharmacological revolution that dominates modern psychiatry has stalled in the case of borderline personality. Antipsychotic drugs or mood stabilisers can help lessen some symptoms, but last year a systematic review of clinical trials concluded that such drugs make little difference to the disorder’s overall severity.

Another successful approach is mentalisation-based treatment, pioneered by Bateman and Peter Fonagy at University College London. MBT comes from the tradition of psychoanalysis, and concentrates on getting people with borderline personality to better understand their own and others’ mental states. It has been less widely studied, but seems to reduce suicide attempts and the use of psychiatric services, while increasing people’s ability to hold down a job.

For Lemonsky, who had found previous therapists dismissive of what seemed to them trivial issues, the last aspect was a revelation. “Whatever I said was treated with the utmost importance,” she says of her experience in Bateman’s clinic.

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