How Borderline Personality Waxes and Wanes Throughout Life
A new study traces the life challenges of people with BPD.
Posted Jun 18, 2019
The fundamental assumption behind the diagnosis of personality disorders is that they are essentially built into the hard-wiring of the individual. Once diagnosed with a personality disorder, the theory is that the individual will never be able to shake off its symptoms.
Borderline personality disorder (BPD) is no different, according to this view. The instability of self, difficulties with boundaries, and emotional dysregulation, to name a few of its symptoms, may be treatable, but the underlying personality structure that produces them is not.
However, are these assumptions valid? Perhaps individuals with borderline personality disorder manage to receive treatment that not only helps alleviate symptoms but also provides fundamental, underlying change. Even without treatment, how might they adapt as they face adulthood's challenges?
To understand the true course of borderline personality disorder requires a lifespan perspective. Taking this approach, a Dutch team of personality disorder researchers headed by Arjan Videler, of the Clinical Centre of Excellence for Personality Disorders and Autism Spectrum Disorders in Older Adults (Tilburg), examined the available evidence in the literature on the course of borderline personality disorder over adulthood.
The authors began their study by noting that, “Until around 1900, therapeutic nihilism prevailed concerning the treatment options for BPD” (p. 51). New methods developed since then have been shown to be effective, including dialectical behavioral therapy (DBT), mentalization-based treatment (MBT), transference-focused psychotherapy (TFP), and schema therapy.
Studies evaluating these treatments stopped at about the age of 40 in their patient samples. To understand both the course of BPD and its amenability to treatment, Videler and associates assert that the age period needs to be extended until later life.
From a lifespan perspective, according to Videler et al., there is “a lifelong vulnerability of impairments in personality functioning, including poor mentalizing and impaired social cognition, along with persisting maladaptive traits like impulsivity, emotional lability, and separation insecurity.”
Affecting whether symptoms worsen or improve, the authors believe, are “complex and changing nature-nurture interactions from early childhood onward” (p. 51). Of course, these complex nature-nurture interactions affect everyone, not just those with BPD.
In your own life, there may be periods in which you feel more or less able to handle the stresses that come your way. Relationships may come and go, job demands can become overwhelming or exhilarating, and even the larger social context of what’s happening in the world can help you feel more optimistic or dejected about the prospects the future holds for you.
The point of the Dutch study was to find out whether such changing circumstances have a particular influence on people whose personality makes them especially vulnerable to these influences. Developmental changes within the individual such as those associated with aging may affect individuals with BPD differently as well.
Reviewing all articles on BPD that incorporated a lifespan perspective from between the 2014 and January 2019, the authors selected 33 studies for review, out of 145 potential articles from a preliminary search. The criteria for including an article in their review, in addition to the term “lifespan” or “course” as a focus of the article, were that they examined risk factors, assessment, and treatment. The authors divided their review into sections based on age period. The following are the summaries for each.
Adolescence. BPD’s origins prior to early adulthood have only recently been the subject of empirical study. The appearance of BPD’s symptoms in adolescence, according to Videler et al., are similar to those of their peers who will go on to be psychologically healthy: “Impulsivity, identity issues and affective instability diminish in the course of adolescence in healthy youngsters” (p. 51), but they do not go away in those who develop BPD.
The majority of individuals with BPD describe their symptoms as first manifesting in adolescence, if not before the age of 13. The factors associated with increased risk of developing BPD include family adversity, limited social resources (wealth and education), psychopathology in the mother, harsh parenting, sexual abuse or neglect, and a range of symptoms of other disorders (e.g. conduct disorder or substance abuse).
As of yet, the authors note that the risk factors for BPD in adolescence cannot reliably be distinguished from those of other disorders. However, noting these risk factors helps to provide a basis for an understanding of BPD.
Adulthood. The symptoms of BPD gradually shift from early to middle adulthood from inability to control emotions, impulsivity, and suicidality to “maladaptive interpersonal functioning and enduring functional impairments, with subsequent periods of remission and relapse” of the full BPD diagnosis.
The authors claim that almost half of BPD patients never fully recover. The risk of suicide remains in as many as 10% of BPD individuals but in general, the acute symptoms of suicidality, self-harm, and impulsivity diminish, while remaining constant are the underlying, “temperamental” symptoms of sadness, emptiness, and fear of abandonment.
Unfortunately, making matters worse for adults with BPD is the fact that their life might have gotten off to a very difficult start, meaning that they never become fully engaged with adult social roles either in relationships or at work. Even so, there are differences in risk factors among adults with BPD.
If they are more intelligent, have stronger vocational functioning, and score high on measures of the personality traits agreeableness and extraversion and low on neuroticism, they may fare relatively well. Those who do not face not only social difficulties, but are more likely to develop chronic illnesses and to die at younger ages.
Late life. Later adulthood is the least well-investigated period of life with regard to BPD. The results of cross-sectional studies (i.e. those that compare age groups) suggest improvements occur in the symptoms relevant to suicidality and impulsivity. However, keep in mind that people who do not recover from BPD are at risk of dying younger and therefore are not part of later life samples. Older individuals with BPD retain the underlying qualities of fear of abandonment, selfishness, lack of empathy, and a tendency to manipulate others.
Those older adults who remain impulsive are at higher risk for arthritis and heart disease, primarily as a result of increased obesity. Moreover, older adults who remain impulsive, as well as experiencing chronic feelings of emptiness and having unstable relationships, are also at risk for a higher frequency of stressful life events.
Although the majority of BPD cases arise earlier in life, there are some older adults who show BPD symptoms for the first time. They may be affected by loss of social supports and loved ones, which could serve as “triggers for late-onset BPD” in people who otherwise were able to compensate for personality disturbance.
In evaluating the potential for treatment to alter the lifespan waxing and waning of BPD symptoms, the authors offer the suggestion that, rather than wait until the symptoms are already in full force, psychotherapeutic efforts should focus on interventions that help individuals improve their social and vocational functioning.
Not only should at-risk adolescents be targeted, but so should their parents to prevent transgenerational transmission of BPD. At the other end of the lifespan, older adults could also be given treatments to help adapt to age-specific stressors, such as being in need of care. Treatment can also be directed at caregivers, including behavioral strategies to teach to staff who work with older adults in long-term care facilities.
To sum up, there are many reasons to view BPD in the framework of a lifespan model. Understanding both that people change and how they change can help both prevent some of the negative life outcomes for people whose BPD begins when they are young, and ameliorate some of the losses that can trigger symptoms late in adulthood.
Videler, A. C., Hutsebaut, J., Schulkens, J. E. M., Sobczak, S., & van Alphen, S. P. J. (2019). A life span perspective on borderline personality disorder. Current Psychiatry Reports, 21(7), 51. doi: 10.1007/s11920-019-1040-1