It’s time to reject the notion that people with personality disorders are beyond help
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 .
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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 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 , a specialist in personality disorders at Baylor College of Medicine in Houston, Texas, and president of the 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?”). 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 , 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.
Lemonsky was an archetypal case. Among those seeking therapy, there are roughly three women to every man. Many have chronic feelings of emptiness and engage in impulsive or addictive behaviour. For Lemonsky the big problem was food; for others it is alcohol, drugs, risky sex or wild spending sprees. As they lurch from one crisis to another, people with borderline personality frequently harm themselves or attempt suicide – primarily as a means of releasing unbearable tension. “It was almost like pain relief,” Lemonsky explains.
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.
For those in the firing line, the onslaught can seem unrelenting. People with schizophrenia may show glimpses of a “beautiful mind”, while those with bipolar disorder can exude personal magnetism during their manic episodes. But when the problem is as fundamental to the human condition as personality, and consistently propels someone into unstable and stormy relationships, it’s hard to keep coming back for more. Families fracture, friends back off, and even professional carers burn out.
“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.”
It’s now clear that even psychiatrists who built their careers around treating people with borderline personality disorder had for years been labouring under a misconception that it is a lifelong affliction. That dogma has been overturned by two studies which have each followed a large group of people with the condition for a decade. Neither study tested a specific treatment but observed what happened to those receiving standard care.
Road to recovery
The first study, led by 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 ().
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 ().
“I’ve been immersed with these patients and I didn’t anticipate it,” says , 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.
“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”), 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 ().
The best results come from specialised psychotherapies, including dialectical behaviour therapy, developed by . DBT is a type of cognitive-behavioural therapy that draws on the Buddhist concept of “mindfulness” – calm awareness of the present moment – to get people to change their behaviour. Over a series of clinical trials, it has performed better than standard talking therapies in reducing self-injury, suicide attempts, anger and substance abuse ().
Another successful approach is mentalisation-based treatment, pioneered by Bateman and . 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 ().
Though coming from different traditions, the two systems have much in common. Both are highly structured and start with the premise that the person’s concerns are valid. “One of our core features is that the subjective experience of the patient is taken extremely seriously,” Bateman says.
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.
Still, there’s no quick fix. Lemonsky’s breakthrough came after about two years. She recalls opening a window and being aware of the birds and flowers, rather than her own problems. “Welcome to the world,” said her therapist.
Access to such therapy remains patchy. Lemonsky, who more than a decade later , describes the UK situation as a “postcode lottery”. In the US, insurers routinely baulk at funding lengthy periods of psychotherapy. It’s a false economy, Oldham argues, as untreated borderline disorder causes a huge economic burden through people’s suicide attempts and other crises.
Although the costs can run to tens of thousands of dollars, Bateman and Fonagy have calculated that an 18-month course of MBT is recouped within two years ().
But better therapies are needed. While treatments like DBT and MBT reduce the most disabling symptoms, they aren’t yet able to cure the underlying social impairment. “I struggle with normal healthy relationships even now,” says Lemonsky. And for other personality disorders, which haven’t been subjected to the same intensive study, treatment options remain sadly limited.
Yet if studies of borderline personality are any guide, it’s time to drop the “untreatable” stigma surrounding personality disorders, and redouble efforts to help people find relief. “You have to invest quite a lot to change someone’s personality,” says , the Netherlands. “But it can be done.”
Inside the borderline mind
People with borderline personality disorder often point to traumatic events or neglect as triggers for their condition, but those with the disorder are born that way, as well as made. Genetic factors appear to account for up to 45 per cent of its variance across the population – putting its heritability just a little below that of high blood pressure ().
The genes involved are not known, but presumably affect brain function. Imaging studies show that people with borderline personality have an unusually weak connection between the amygdala, a structure involved in processing emotional reactions, and regions of the cortex that normally inhibit its activity (). John Oldham, a specialist in personality disorders at Baylor College of Medicine in Houston, Texas, likens the result to a car in which the engine is “running hot” and the brakes have failed.
People with borderline personality may also react unusually to oxytocin, sometimes known as the “trust hormone”. Healthy people co-operate more after oxytocin is sprayed into their nose, but found that the hormone had exactly the opposite effect on a group of people with borderline personality ().
What’s in a name?
Fixing a broken personality is one thing, but can psychiatrists fix the diagnostic framework for personality disorders? Many agree that it’s in dire need of an overhaul.
The American Psychiatric Association’s current Diagnostic and Statistical Manual of Mental Disorders (DSM) lists 10 distinct disorders (see diagram), which are diagnosed if a person’s symptoms exceed a threshold number from a checklist. But when psychiatrists rigidly apply these criteria, they often find that their patient is diagnosed with several disorders simultaneously. Some people with clearly dysfunctional personalities do not fit into any category: more than 20 per cent may end up being diagnosed only with “personality disorder – not otherwise specified” ().FIG-mg28272401.jpg
What should replace this creaking edifice? The would consign four of the existing disorders to the scrap heap. Diagnosis of the remaining types would happen only if people score poorly on scales for two areas of personality functioning – self and interpersonal – and high for five pathological personality traits, including antagonism and impulsivity. These traits are designed to assess pathological personalities in a similar way to how psychologists use the “” traits of openness, conscientiousness, extraversion, agreeableness and neuroticism to measure normal personality variation. But critics argue that this system is way too complex to be practical. “I think they are operating in a parallel universe,” says at the University of Colorado School of Medicine in Denver.
Shades of grey
at the University of Arizona in Phoenix, who chairs the panel responsible for the proposal, defends his group’s work, arguing that the system is simpler than the current checklists. Critics are simply reacting against change, he suggests, as happened with previous revisions.
A group headed by London argues that diagnosis should concentrate on interpersonal problems, judged on a scale of severity, after which people should be assigned to one of five “domains” of personality disturbance, which would replace the existing domains ().
The proposals acknowledge that personalities are not black-and-white but come in shades of grey. That point was driven home last year by a survey led by Tyrer of more than 8000 British people. Previous studies suggest that between 4 and 12 per cent of the population has a personality disorder, according to the DSM criteria – although most are never diagnosed. When Tyrer and his colleagues expanded the screening to include people with “personality difficulties”, they found that only 23 per cent were free of pathological personality traits ().
If you think about it, this surprising finding starts to make sense. Who hasn’t felt the fear of rejection, put themselves in danger by acting impulsively, or regretted an angry outburst? People with personality disorders have long been stigmatised as victims or monsters. In reality, they are like the rest of us – only more so.
