Borderline personality remits in 73.5% of cases: prognosis brighter than most assume. (First 6 Years).

NEW YORK -- The prognosis for patients with borderline personality disorder may be considerably brighter than psychiatrists generally assume, according to two longitudinal studies reported at a conference on borderline personality disorder sponsored by Columbia University.

As many as three-fourths of patients remitted by 6 years in one study. In the other, more than half no longer met syndrome criteria after 2 years.

Mary C. Zanarini, Ed.D., director of the laboratory for the study of adult development at McLean Hospital, Belmont, Mass., reported results of a study that began 10 years ago, involving 290 inpatients with borderline and 72 with other personality disorders.

Two hundred and seventy five borderline patients were evaluated at 2 years, 269 at 4 years, and 264 at 6 years. Eight-year data is 90% complete, and collection of 10-year data will begin in June.

The most striking finding of the study was that nearly three-fourths--73.5%--if the borderline patients achieved remission in the course of the first 6 years. For one-half of these, the time to first remission was 2 years, and the rest was equally divided between 4 and 6 years, Dr. Zanarini said at the meeting, also sponsored by the National Education Alliance for Borderline Personality Disorder.

Few (6%) of remitted patients had symptomatic recurrences. These tended to be related to "catastrophic" stress, and were generally brief, she said.

The rate of suicide was considerably lower than expected: 1.4% in the first 2 years, 1.7% in the next 2, and 0.7% in the following 2, for a total of 3.8%. There were no additional suicides between the sixth and eighth year of the study, she said.

Functional improvement was also robust in the sample. Two-thirds (65.9%) achieved good psychosocial function in the course of the study: 32.4% after 2 years; 48.3% after 4; and 54.6% after 6. Sixty percent of patients, overall, achieved both remission and good functional status.

As for subsyndromal phenomena, impulsive symptoms improved most, affective symptoms least, and cognitive and interpersonal symptoms to an intermediate degree, Dr. Zanarini said.

Acute manifestations such as self-mutilation, suicidal efforts, and psychotic thoughts declined more rapidly than temperamental symptoms, she said.

Dr. Andrew Skodol, professor of psychiatry at Columbia University, reported a 5-year, five-site collaborative study that enrolled 175 patients with borderline disorder, along with 493 with other. Axis II disorders or major depression. It included annual follow-up evaluations with weekly and monthly ratings of symptom and functional status.

For 10% of the borderline patients, syndromic remission was rapid; all patients with the disorder met five or more DSM-IV criteria at the outset of the study but by 6 months, 18 met two or fewer.

Situational change (ending a destructive relationship, for example) was the most important determinant of improvement in 10 cases, and remission of a cooccurring disorder, such as substance abuse, in seven. One patient had been misdiagnosed.

At 2-year follow-up, 14 of these patients were in full remission, Dr. Skodol said.

Over the first 2 years of the study, less than half (44%) met full criteria for the diagnosis: 43% had periods of 2 months or more when they met two or fewer criteria; for 28%, such periods extended over at least 12 consecutive months, he said.

Functional improvement tended to lag behind symptoms and was less complete. For the group overall, there was no significant change at 2 years. For those who had improved symptomatically employment, recreation, and global function were better, but social relations were not.

"Functional impairment in social relations was most persistent," he said.

Because these were naturalistic studies, the role of treatment in the clinical course was impossible to determine. Dr. Zanarini noted that hers was "a very heavily treated sample," most of whom had had individual psychotherapy and medication.

But her impression was that patients' willingness to struggle to get well was the most important prognostic factor. "A fighting spirit ... trumps psychotherapy and medication," Dr. Zanarini said. "These people deserve our respect as well as our empathy."