BPD Researcher Searches for Puzzle's Missing Piece

In the early 1970s, John Gunderson, M.D., was assistant chief at the National Institute of Mental Health (NIMH) Center for Studies of Schizophrenia, with plans to devote a career to understanding and treating psychosis, when Otto Kernberg, M.D., published reports on the intrapsychic structure of patients who presented with what came to be known as borderline personality disorder (BPD).

From his earliest days in training, Gunderson had seen patients who matched Kernberg's description—emotionally volatile, impulsive, and potentially aggressive, with a history of unstable relationships and frequent self-harming. Recalling his early exposure to the disorder, he admitted to an "almost voyeuristic fascination" with these patients, who were considered uniquely "difficult" and whose lives were often spectacularly chaotic.

He started to collect descriptive accounts of patients with a condition that had garnered the name "borderline," because it was believed at the time to inhabit a border between psychosis and neurosis. "The Schizophrenia Center was a good place to be doing this," he recalled, "because at the time the disorder was considered an atypical form of schizophrenia."

Photo courtesy of John Gunderson, M.D.

Largely because of Kernberg's influence, BPD became a topic of interest within the psychoanalytic community—Gunderson had trained at the Boston and Washington psychoanalytic institutes and worked as a research fellow at Chestnut Lodge, famed for its long-term psychodynamic approach—and in 1980 BPD entered DSM.

The criteria adopted at that time for BPD have remained largely the same to this day, with only minor modifications: intense, unstable relationships marked by idealization and devaluation; fears of abandonment; unstable self-image; impulsive behavior; brief but intense episodes of depression, irritability, and/or anxiety; chronic feelings of emptiness; intense anger; episodic stress-related paranoia and/or dissociative symptoms; recurrent suicidal behavior; and recurrent acts of self-mutilation.

By the mid-1980s, Gunderson had begun to attract referrals to care for patients who met the criteria, and almost in spite of himself, the schizophrenia expert-to-be became an expert on BPD. In 1984 he published a textbook, Borderline Personality Disorder (American Psychiatric Press Inc.), that would be followed by some 15 other books and monographs on BPD and personality disorders (among other topics) and more than 200 peer-reviewed research publications.

From 1996 through 2009, he was a principal investigator and chair of the steering committee for the Collaborative Longitudinal Personality Disorders Study (CLPS), a multisite NIMH study that has markedly advanced the understanding of BPD and other personality disorders as hybrids of stable personality traits and intermittently expressed symptomatic behaviors and of their long-term course.

Today, he is staff psychiatrist at McLean Hospital, where he has spent all of his career since leaving NIMH. What began as intellectual fascination has evolved into a passion for the appropriate treatment of people with a disorder that Gunderson believes has for too long been stigmatized by clinicians themselves.

"Here at McLean, the culture is one in which all of our people are extensively trained in the treatment of BPD and other personality disorders," he said. "Patients with this diagnosis have suffered so much stigma and discrimination; they really deserve the best treatment by skilled clinicians."

Symptoms Improve, but Not Functioning

The period since Gunderson first became fascinated with BPD has witnessed enormous expansion in the understanding of the heritability of the disorder and of its longitudinal course.

Among the more startling findings from CLPS and from the McLean Study of Adult Development (another longitudinal study of personality disorders, led by Gunderson's colleague at McLean, Mary Zanarini, Ed.D.), is that over time patients with BPD tend to get better symptomatically though they may not improve functionally. In an extension of the McLean Study of Adult Development that appeared online in AJP in Advance in April 2010, Zanarini and colleagues found that a substantial majority of patients with BPD experience remission of symptoms and that their remission tends to be stable over time compared with patients with other mental disorders (Psychiatric News, May 7, 2010).

But crucially, the study also found that only half of patients achieve good social and vocational functioning. So, for instance, while patients may cease cutting themselves or exhibiting other self-harming behaviors, some may remain unable to maintain close long-term relationships or a job.

"These patients experience significant remission in their psychopathology," Gunderson told Psychiatric News. "The remission in BPD occurs more slowly than for bipolar disorder or major depressive disorder, but about 85 percent of patients over a 10-year period will remit, which no one ever thought to be the case. And when they remit, they rarely relapse. But at the same time, many remain dysfunctional so that their public-health cost to society remains high, even though they may stop needing some treatment."

The finding has important implications for long-term outcome of treatment, since many of the psychotherapies for BPD are focused on specific domains of pathology but may not address long-term functioning.

Unifying Pathway for "BPD-ness"

Today, that insight is being advanced in a paper by Gunderson and colleagues in press with the Archives of General Psychiatry. The authors suggest that the separate domains of pathology that have been used diagnostically to identify BPD—emotional instability, impulsive aggression, interpersonal hypersensitivity—may be expressions of a common, as-yet-to-be-identified pathway, some X factor of dysregulation that is the core of "BPD-ness."

The study assessed the familial aggregation of BPD and its four major symptom "sectors" (defined as affective, interpersonal, behavioral, and cognitive) and tested whether the relationship of the familial and nonfamilial associations among the sectors can be accounted for by a "latent BPD construct" or unifying pathway.

What they found was substantial familial aggregation for BPD; they also found that all four sectors of psychopathology aggregated significantly in families. But the level of familial aggregation of BPD itself was higher than that of the individual sectors, suggesting that the relationship among the sectors must be explained by some common, unifying pathway.

The study suggests that efforts should be made to identify endophenotypes associated not only with individual sectors of BPD, but also with a more global tendency toward dysregulation that involves the several sectors of symptoms that together present as BPD.

Gunderson believes that the future of BPD research lies in unearthing this X factor, the common pathway for the behavioral endophenotypes that show up as the disorder.

"There is some kind of core to borderline pathology that is not about being either impulsive or emotional or interpersonally sensitive, something that isn't wholly captured by any of these characteristics," he told Psychiatric News. "This is important because our treatments that target one or another sector of behavior in BPD are not likely to get at the core."

"Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-Year Prospective Follow-Up Study" is posted at <http://ajp.psychiatryonline.org/cgi/content/abstract/167/6/663>.