Outcome in borderline disorders - A review of short-term, intermediate andlong-term follow-up perspectives

This paper reviews the current state of research results on borderline diso rders in terms of course and outcome, variables predisposing to good or poo r outcome, suicide rates and the influence of psychotherapeutical and pharm acotherapeutical strategies. It turned out that course and outcome of borde rline disorders depend on the applied diagnostic criteria and on the length of the follow-up period. The outcome of the follow-up studies of borderlin e schizophrenia and of the borderline syndrome according to Grinker was on the whole worse compared to those of borderline personality disorder define d by DSM-III/III-R or DIB according to Gunderson or Kernberg's criteria. Fu rther, it could be shown that the GAS or HSRS values of the short-term foll ow-up studies (up to five years) ranged from 46.4 to 59.2 points whereas th ose of the long-term studies with an average period of 13.6 till 20 years w ere measured in the lower and in the mid-60 s that reflects only mild diffi culties in psychosocial functioning. However, the high rate of completed su icide in BPD was to be respected: The most extensive followup investigation with the highest trace-rate (PI-500) revealed a suicide rate of 9% till no w, and the most lethal combination of circumstances was BPD x MAD x alcohol abuse (suicide rate of 38%). Prognostic factors predisposing to poor outco me were substance abuse, admixture with antisocial and schizotypal elements , chronic hostility and affective instability with depressive and anxious f eatures. Prognostic factors predisposing to good outcome were high IQ, extr aordinary talent, high attractiveness, likeability and regular appointments with the Alcoholics Anonymous. Finally, the influence of psycho- and pharm acotherapeutical interventions were controversially debated. Several psycho dynamic therapy studies resulted in satisfactory outcome scores concerning a subgroup of patients with personality traits like warmth, likeability rel iability, talent. Behavioral treatment strategies such as dialectical behav ior therapy by Linehan significantly diminished parasuicidality and impulsi veness. Psychopharmacotherapy should target predominating psychopathologica l features: Low-dose antipsychotics against micropsychosis and prolonged se vere dissociative symptoms, SSRIs and MAOIs against affective instability, and, lithium., carbamazepine or valproate against severe impulsiveness and aggressiveness.