Prognosis of Personality Disorder Dr Sofia Zarate Escudero ST5 Research Fellow Central and North West London NHS Foundation Trust IMPERIAL COLLEGE LONDON Prof Mike Crawford

BACKGROUND Providing people with information about their condition Aetiology, treatment options Prognosis: ‘Will I get better?

AIM Review existing literature Estimate the true Prognosis for PD Focus on : Remission of PD Mortality (Suicide) Quality of Life Social Functioning

METHOD Systematic search of electronic databases (MEDLINE, EMBASE,OVID AND PSYCHINFO) PRISMA Guidelines Inclusion/Exclusion Criteria Prognosis: Proportion of individuals, who still met diagnostic criteria after the period of follow up was completed.

INCLUSION CRITERIA Meet a diagnosis of personality disorder either by ICD, DSM or DIB Majority of subjects aged > 18 years Clinical setting, including inpatient ,community, forensic & specialist treatment services. Retrospective, prospective, longitudinal and observational studies Articles published in English, French and Spanish Presence of Axis I disorders Presence/ absence of treatments received by the subject both psychological and/or pharmacological

EXCLUSION CRITERIA Studies that are based on populations that have personality disorder and psychosis (other comorbidities will be included) Studies that are based on populations with cognitive impairment and/ or organic brain disorder. Case series and case studies of less than 10 patients Randomised controlled trials

RESULTS 34 papers used in systematic review 10 papers for Prognosis 14 papers for Suicide 5 papers psychosocial Functioning 1 paper for interpersonal relationships Collaborative Longitudinal Personality Study (CLPS) McCLEAN/ MSAD CHESTNUT LODGE STUDY PI 500

RESULTS 29 from USA, 4 from Europe, 1 from Asia (Japan) 26 studies in patient, 7 community 1 both

PROGNOSIS OF PERSONALITY DISORDERS- REMISSION OF SYMPTOMS TABLE 1 PROGNOSIS OF PERSONALITY DISORDERS- REMISSION OF SYMPTOMS

5.9% experienced remissions Study Type of PD YEAR 1 YEAR 2 YEAR 5 YEAR 10 YEAR 15 YEAR 20 NOTES Barasach ( 1985) BPD - 40% CLPS ( 50% Kullgren & Aremlius ( 1990) 45% Small Sample Size Links,et al (1998) 52.6% 6 YEARS McClean ( MSAD) 88% 6% relapsed Mehlum et al (1994) 58% McGlashan 56% McMaster 50% * 7 Years Panfilis 26.1% Paris,Brown & Nowlis 75% Zanarini 85% 5.9% experienced remissions GFDGFDGFDGF

PROGNOSIS SUMMARY 15Yrs 56% 20Yrs 75% 2 Yrs 26.1 - 58% 5 Yrs 44% - 52.6% 10 Yrs 85 - 88% 15Yrs 56% 20Yrs 75%

COMPLETED SUICIDE & SUICIDE ATTEMPTS TABLE 2 COMPLETED SUICIDE & SUICIDE ATTEMPTS

(prospective/ retrospective) Duration of follow up Study Country No Participants Study design (prospective/ retrospective) Duration of follow up Population (IP/ out-patient etc) Measure of Impulsivity Suicide Attempts Completed Suicides Andreoli et al (1989) Switzerland N=27 (DSM III-R) Prospective 2 years Inpatient 3 weeks Outpatient 6 weeks NONE NOT DOCUMENTED 3.7% Akiskal et al ( 1985( USA N=100 6-36 months Outpatient 1% Antikainen, et al. (1995) Finland (124 people with BPD based on DSM-IV) 3 years Inpatient Therapeutic Community 29% 2.4% Black, et al. (1985) N= 5412 (ICD 9) Prospective investigation 4 years 20.5% Links,et al (1998) N= 88 7 years Inpatients 4.6% 3.2% McGlashan N=94 20 years Inpatient Attempted Suicides > 1= 21% 3% Mehlum et al ( 1994) Norway N=97 2.8years 28.6% in suicide attempter group 11.8% in non attempters Modestin et al (1989) N=53 4.5 Years 8% Senol et al ( 1996) Turkey N-= 75 2-4 year 71% attempted suicide 3.28% Stone et al ( N= 10-23 years 7.6% Paris et al ( 1987) 15 Years 27 years DIB scores  from (1.44-0.33) 8.5% 10.3% Tucker et al (1987) N=40 2 Years Yr1: 30% Yr 2: 25% Yoshida et al ( 2006) Japan N=72 Retrospective 16 years 6.9% Zanarini et al ( 2007) N=362 10 year 15%

SUICIDE SUMMARY

Psychosocial Functioning TABLE 3 Psychosocial Functioning

Study YEAR 1 (Initial) YEAR 2 YEAR 4 YEAR 5 YEAR 6 YEAR 10 Barasach 51.4 - 59.2 (*Yr 3) McClean ( MSAD) (0.0) 14.2 24.5 32.6 Senol (1996) (40.86) 46.42 Tucker (1987) (29.67 at Admission) Discharge 41.56) Yr. 1 F/up: 50.33 56.50 -- Zanarini (2007) 14.2% 24.5% 32.6%

VOCATIONAL PERFORMANCE

VOCATIONAL PERFORMANCE REMITTED BPD NONREMITTED BPD Disability Payments BL 2 Yr F/up 4 yr F/up 6 F/up 35.6% 44.1% 43.8% 38.0% Disability Payments BL 2 Yr F/up 4 yr F/up 6 F/up 56.2% 67.1% 75.0% 73.4% (Psychosocial Functioning of borderline Patients and Axis II Comparison Subjects Followed Prospectively for Six Years. Zanarini et al 2005)

INTERPERSONAL RELATIONSHIPS Psychosocial Functioning of borderline Patients and Axis II Comparison Subjects Followed Prospectively for Six Years. Zanarini et al 2005

INTERPERSONAL RELATIONSHIPS Remitted BPD Pts Nonremitted BPD Pts Relationships BL 2 Yr F/up 4 yr F/up 6 F/up Married/ Living with partner 15.4% 19.8% 30.4% 38.0% Children 16.3% 17.3% 23.9% 27.5% Relationships BL 2 Yr F/up 4 yr F/up 6 F/up Married/ Living with partner 16.4% 13.7% 16.2% 14.1% Children 26.0 27.9 26.6

No papers found or identified QUALITY OF LIFE (QoL) No papers found or identified

RESULTS Findings limited to BPD 85% at 10 years no longer met diagnostic criteria Limited information on functioning & interpersonal relationships No information on Quality of Life(QoL)

LIMITATIONS OF STUDIES Reliance on inpatients Diverse follow-up measures Lack of check on inter-rater reliability High attrition rates Variable follow-up times USA Studies (all but 5)

LIMITATIONS OF REVIEW Work in Progress Grey Literature not searched No contact with expert authors (until now!) Many studies rejected that did not use established diagnostic criteria Quality rating- ongoing

THE FUTURE…. Diagnostic Criteria ICD 11 / DSM 5 Wider group than those with BPD Standardized measures Standardized time points (2, 5, 10 years) Include measure of Quality of Life (QOL) Tell patients what they need to know!