MSAD: the longitudinal study that has been dealing with Borderline Personality Disorder for 26 years

MSAD: the longitudinal study that has been dealing with Borderline Personality Disorder for 26 years

The MSAD has allowed over the years to observe and describe many aspects of patients with BPD. The study sought both to grasp the peculiarities of the pathology, and to analyze the subjects beyond their disorder, exploring their experiences, lifestyle, the reference environment and personal characteristics.

Francesca Frigerio – OPEN SCHOOL, Cognitive Studies Milan


Borderline Personality Disorder (BPD) has received increasing attention over the years due to the increase in its spread within the population, the resulting social impairment and the large use by these patients of mental health services (Zanarini et al. 2005).

During the post-graduate internship I had the opportunity to work for 6 months in the laboratory directed by Ed.D. Mary Zanarini, leading exponent in the psychological landscape and university professor at the Harvard Medical School in Boston. Within this context, I was able to closely observe his work and participate in the MSAD (McLean Study of Adult Development) research project, one of the first studies with the aim of describing the course and outcome of the Bordeline Disorder of Persoalità.

This project was born in 1992 thanks to the work of Ed.D Mary Zanarini and his colleagues and collaborators in the setting of the McLean Hospital in Belmont (Massachusetts, USA), the reference hospital for the medical faculty of Harvard University. This is a 26-year longitudinal study involving 362 subjects: 290 who met the criteria for Borderline Personality Disorder and 72 who met the criteria for another Personality Disorder (OPD). The initial sample was selected from the pool of patients who were admitted to the hospital between March 1991 and December 1995 (Morey et al. 2000).

To be admitted to the research, the subjects had to meet certain inclusion criteria: be aged between 18 and 35, a diagnosis for an Axis II disorder (DSM-III-R), an IQ greater than 71, speak fluently English and not presenting a history or symptomatology attributable to an organic disorder, a spectrum disorder of Schizophrenia or a Bipolar I Disorder (Morey et al. 2000). Over the years, most of the participants hired at the baseline have lent themselves to data collection every two years. The dropout rate and outages caused by accidental death or suicide were not particularly high (more than 70% of the participants completed the study) (Temes et a., 2019).

Over the years, the subjects have been tested using a battery consisting of self-administered and hetero-administered questionnaires, designed specifically to study their life, personal characteristics and the progress of the pathology. The battery, in fact, included tools that were intended to collect data:

Most of the baseline analyzes were aimed at investigating the role of adverse life events in the etiopathogenesis of BPD. These studies have shown that the severity of sexual violence suffered in childhood and other forms of abuse and neglect can play an important role in the symptomatic severity and impairment of psychosocial functioning, typical of patients with BPD (Zanarini et al. 2002 ). Sexual abuse is neither necessary nor sufficient for the development of the disorder, but early adverse experiences, particularly neglect by caretakers of both sexes, appear to represent significant risk factors (Reich et al. 1997).

Within the study, special attention was given to the comorbidity of BPD with other psychopathologies, both belonging to Axis I and II of DSM-III-R. In particular, with respect to comorbidity with Axis I pathologies, it has been noted that Post Traumatic Stress Disorder (PTSD) seems commonly, but not universally, associated with BPD, in contrast to the idea that Borderline pathology was nothing more than a chronic PTSD. Eating disorders were more common in women, while substance use disorders in men. On the other hand, Anxiety Disorders and Mood Disorders seem equally present in the population of patients with BPD (Zanarini et al. 1998).

As regards comorbidity with Axis II disorders, a particularly close relationship has emerged between BPD and anxious cluster disorders. Furthermore, there seems to be an important difference between genders: although the frequencies of Avoidant and Dependent Personality Disorders were similar, Paranoid, Passive-aggressive, Narcissistic and Antisocial Personality Disorders were much more common within the male population ( Zanarini et al. 2018).

The large pool of information obtained from the 24 years of follow-up also made it possible to analyze the evolution of the pathology and the changes in the living areas of the subjects examined. In fact, many aspects are analyzed in most of the follow-ups in order to be able to monitor progress continuously, such as the predictive factors for obtaining recovery from BPD. In the study, recovery is defined as a follow-up period of at least 2 years during which patients no longer met the criteria for the diagnosis of DBP and showed good psychosocial and professional functioning. Over the course of 20 years, in which only 39% of patients with BPD achieved recovery compared to 73% of the control sample (OPD), 5 variables have been identified that seem to be predictive of excellent healing: a higher IQ, a sufficiently serene childhood, a good professional history in adults, low traits of neuroticism (neuroticism) and high rates of agreeableness. The results of these research suggest that complete recovery is difficult to achieve for patients with BPD, even in the long term (Zanarini et al. 2006).

The MSAD has also addressed some of the most delicate issues concerning this pathology, such as suicidal risk and self-injurious gestures. After 24 years, the number of BPD patients who died following a suicidal act was much higher than that of subjects with OPD (5.9% vs 1.4%). The researchers also found that people with BPD are generally more at risk of premature death than the control population, in fact, even the number of non-suicidal deaths far exceeded that of patients with OPD (14.5% vs 5.5%). The risk of suicide and non-suicidal death in subjects with BPD appears to be disproportionately higher in subjects who have not achieved recovery (Temes et al. 2019).

As for self-injurious gestures, on the other hand, 91% of the sample of patients with BPD examined reported a history of self-mutilations, distributing themselves fairly linearly compared to the age of onset of these practices (32.8% before of 12 years, 30.2% between 13 and 17 years and 37% after 18 years). Analyzing in greater detail the data obtained from the subjects, it emerged that patients with an infantile onset of self-injurious acts seem to report more episodes, a constancy over time and a greater number of methods used for self-mutilation compared to those who started these practices in adolescence or adulthood (Zanarini et al. 2006).

The more classic themes were alternated with the exploration of more original and less treated aspects of the disorder, such as the frequency of use of mental health services, associated chronic diseases or quality of sleep. With respect to the latter topic, after showing the possible association between the absence of sleep disturbances and the recovery status of patients with BPD (Plante et al. 2013), the researchers focused on dysfunctional thoughts and attitudes towards to sleep. From the analysis of the collected data it appears that patients with non-recovery BPD have a significantly higher rate of maladaptive cognition related to sleep than subjects who have achieved a healing state (Plante et al. 2013).

Over the years, the MSAD has allowed us to observe and describe many aspects of patients with BPD, trying both to grasp the peculiarities of the pathology, and to analyze the subjects beyond their disorder, exploring their experiences, lifestyle, context in which they are inserted and personal characteristics. The analyzes on the large sample were carried out for 26 years, generating a sequence of photographs which gave the possibility to monitor the progress of many aspects continuously. Furthermore, the MSAD offered many food for thought, useful for deepening the characteristics examined or for studying new ones.