Line of Sight

During his residency at Massachusetts Mental Health Center in the late 1960s, John Gunderson, MD ’67, was troubled by a type of patient that he and his colleagues would see regularly. Nearly all of these patients came in following a suicide attempt. All were angry, very angry, and all would complain about being mistreated by or alienated from members of their family or their romantic partner. They created, he said, significant problems for the staff.

“We didn’t have a diagnosis for them,” said Gunderson, during an interview shortly before his death in January. “The half of us who felt these people needed our sympathy would diagnose them with depression. Those of us who disliked them classified them as atypical schizophrenics, seeing them as manipulative. We’d try to get them out of the hospital quickly. To the patients, this only confirmed their sense of being mistreated and rejected, further worsening their condition.”

“We misdiagnosed them, misunderstood them, and mistreated them,” he added. “I felt frustrated because I was one of those people who vacillated.”

Gunderson, who retired in 2018 from his role as director of the McLean Borderline Center, entered psychiatry at a time when evidence-based research in the field was on the ascent. Early in his residency he began a major research project to determine the effectiveness of psychoanalysis for schizophrenia. At the time, he thought it might validate the psychoanalytic approach used by his mentors to treat patients with schizophrenia. It proved the opposite.

“I showed it wasn’t particularly effective for those with schizophrenia,” said Gunderson. “My findings were disillusioning but informative. They allowed me to step back from psychoanalysis and realize the need to empirically prove the efficacy of treatments, to not stand on the merits of tradition and endowed wisdom.”

With eyes newly opened, Gunderson conducted a small study at Mass Mental Health designed to characterize what some described as “wastebasket” patients. His drive to understand these patients grew and by the early 1970s, as a research fellow at the National Institute of Mental Health, he was collaborating on research to create diagnostic criteria that distinguished them from patients with schizophrenia. That work was followed by a literature review, “Defining Borderline Patients: An Overview,” coauthored with clinical psychologist Margaret Singer and published in 1975 in the American Journal of Psychiatry. He then embarked on a collaborative effort to develop a structured interview that would ensure reliable diagnoses of the disorder and also provide a set of discriminating characteristics. By 1980, borderline personality disorder was included in the DSM III as a distinct personality disorder.

The field began to recognize Gunderson’s pivotal work. He went, he said, from being “a failure as a treater to an expert on a group of patients that really confused and disturbed me.” For nearly five decades, he continued to study this disorder, leading many to consider him its “father.”

Throughout the decades, Gunderson innovated, developing a supportive intervention that involved families; describing children with the disorder as exhibiting interpersonal hypersensitivity, a characterization that incorporated genetics into the psychological theory of the disorder; and developing a new therapeutic approach called general psychiatric management. Many consider this generalist model especially notable because of its potential to serve the public health needs of patients with the disorder.

Among the psychotherapies considered effective for borderline personality disorder, dialectical behavior therapy has been the leading, and best-studied, one. It has been shown to significantly reduce patients’ need for additional treatments such as hospitalization or medication and to decrease episodes of self-harm or suicide by half. Furthermore, research has shown patients who underwent this therapy maintained their improved status for between two and five years. The approach, however, calls for the patient to commit weekly to more than five hours of individual and group therapy and requires therapists to participate in two five-hour trainings.

General psychiatric management, by contrast, requires a single hour of individual consultation each week; caregivers need only participate in a one-day workshop to gain or hone the skills needed to supervise therapy. Although general psychiatric management has not been studied as much as its dialectical cousin, a major randomized controlled trial has shown it to be as effective as high-quality dialectical behavior therapy. In 2016, the American Journal of Psychiatry published a paper by Gunderson in which he “served notice of the emergence” of this model. Notice was taken: A few years ago, Gunderson said, a sixty-page clinical guide for this therapeutic approach began to be distributed to U.S. medical residents.

Broadening the understanding of borderline personality disorder and arming physicians with a therapeutic intervention is necessary given the prevalence of this illness. It is estimated that the disorder is found in 1.7 percent of the general population, 6 percent of primary care patients, and between 15 and 28 percent of patients in psychiatric clinics or hospitals. Recent heritability studies, which Gunderson drew upon when constructing his interpersonal hypersensitivity theory, indicate the variance associated with genetic factors is between 42 and 68 percent, a range similar to that for hypertension.

Reflecting on a career spent researching this disorder, Gunderson considered his to have been a most rewarding one. “I’ve been a part of a small army of people who intently engaged in this work. I have loved it.”

Ann Marie Menting is the editor of Harvard Medicine magazine.

Images: Mattias Paludi (top); Moonassi