1. 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

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

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

4. 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.

5. 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

6. 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

8. 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

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

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

11. 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

12. PROGNOSIS SUMMARY 15Yrs 56% 20Yrs 75% 2 Yrs 26.1 - 58% 5 Yrs
44% %
10 Yrs %
15Yrs
56%
20Yrs
75%

13. COMPLETED SUICIDE & SUICIDE ATTEMPTS
TABLE 2
COMPLETED SUICIDE & SUICIDE ATTEMPTS

14. (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 ( )
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%

15. SUICIDE SUMMARY

16. Psychosocial Functioning
TABLE 3
Psychosocial Functioning

17. 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%

18. VOCATIONAL PERFORMANCE

19. 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)

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

21. 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

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

23. 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)

24. 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)

25. 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

26. 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!