Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop.

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.

Attitudes toward borderline personality disorder: a survey of 706 mental health clinicians.

OBJECTIVE: We sought to determine attitudes toward patients with borderline personality disorder (BPD) among mental health clinicians at nine academic centers in the United States. METHODS: A self-report questionnaire was distributed to 706 mental health clinicians, including psychiatrists, psychiatry residents, social workers, nurses, and psychologists. RESULTS: The study showed that most clinicians consider BPD a valid diagnosis, although nearly half reported that they preferred to avoid these patients. The clinician's occupational subgroup was significantly related to attitude. Staff nurses had the lowest self-ratings on overall caring attitudes, while social workers had the highest. Social workers and psychiatrists had the highest ratings on treatment optimism. Social workers and psychologists were most optimistic about psychotherapy effectiveness, while psychiatrists were most optimistic about medication effectiveness. Staff nurses had the lowest self-ratings on empathy toward patients with BPD and treatment optimism.DiscussionNegative attitudes persist among clinicians toward BPD, but differ among occupational subgroups. Overall, caring attitudes, empathy, and treatment optimism were all higher among care providers who had cared for a greater number of BPD patients in the past 12 months. CONCLUSION: These findings hold important implications for clinician education and coordination of care for patients with BPD.

Reliability and validity of the Borderline Evaluation of Severity Over Time (BEST): a self-rated scale to measure severity and change in persons with borderline personality disorder.

A new self-rated scale to measure severity and change in persons with borderline personality disorder (BPD) is described. The Borderline Evaluation of Severity Over Time (BEST) was developed to rate the thoughts, emotions, and behaviors typical of BPD. Data were collected in the course of a randomized controlled trial (RCT) of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for subjects with BPD. The instrument showed moderate test-retest reliability, high internal consistency, and high discriminant validity. Its 15 separate items showed a moderate or better correlation with the total score. The BEST was also sensitive to clinical change as early as week 4 of the RCT and correlated highly with other measures of illness severity. We conclude that the new scale is both reliable and valid in measuring severity and change in persons with BPD.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up.

OBJECTIVE: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial. METHOD: Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis. RESULTS: Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups. CONCLUSIONS: STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

Relationship of sex to symptom severity, psychiatric comorbidity, and health care utilization in 163 subjects with borderline personality disorder.

OBJECTIVE: The objective of the study was to compare symptom severity, frequency, and pattern of psychiatric comorbidity, quality of life, and health care utilization in men and women with borderline personality disorder (BPD). METHODS: The analysis is based on a sample of 163 subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BPD recruited for participation in a clinical trial at an academic medical center. Subjects were administered structured interviews and questionnaires of known reliability. RESULTS: Men (n = 25) and women (n = 138) with BPD were compared across multiple domains. Men were significantly older than women (34.5 vs 30.4 years), but subjects were otherwise similar in their demographic characteristics. Overall syndrome severity and frequency of past suicide attempts and self-harm behaviors were also similar. Women were more likely than men to have an anxiety disorder (particularly generalized anxiety disorder), somatoform disorders, and histrionic personality disorder. Antisocial personality disorder was more common in men. Women had higher dimensional ratings of depression, anxiety, obsessive-compulsiveness, work dysfunction, and negative affectivity; they were also more likely to endorse the "paranoia/dissociation" BPD criterion. On the Short Form-36 Health Survey, women reported significantly worse emotional role, social role, and mental health functioning than men. Contrary to expectation, there were no significant cross sex differences in the use of health care resources. CONCLUSION: Men and women with BPD show important differences in their pattern of psychiatric comorbidity, dimensional symptom ratings, and in quality of life variables. Women have more negative views of themselves, and worse overall emotional and social role functioning. Implications for clinicians and researchers are discussed.

STEPPS group treatment for borderline personality disorder in The Netherlands.

BACKGROUND: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a new cognitive group treatment for outpatients with borderline personality disorder. METHODS: The English and Dutch language literature was reviewed on the STEPPS program. RESULTS: STEPPS was introduced in The Netherlands in 1998 under the acronym VERS. Reasons for its rapid dissemination throughout Holland include a user-friendly manual, its 20-week duration, ability to maintain the patient's current treatment team, and ease of therapist training. Two pilot studies, one in the US and one in The Netherlands, suggest its efficacy. Randomized controlled trials are now underway. CONCLUSIONS: STEPPS has become widespread in The Netherlands, and is now being modified for other settings, such as programs for adolescents.

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention.

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.

STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder--a preliminary report.

We describe a new cognitive-behavioral systems-based group treatment for persons with borderline personality disorder (BPD). The program is called STEPPS, an acronym for Systems Training for Emotional Predictability and Problem Solving. Briefly, the program combines cognitive-behavioral techniques and skills training with a systems component. The latter involves patients with BPD and persons in their system (e.g., family members, significant others, health care professionals). The program involves 20 two-hour weekly group meetings with two facilitators, is manual-based, and has specific goals to accomplish each week. Here, we review the background and development of the program, and present preliminary efficacy data from a subset of patients which suggest that patients experience improvement in BPD and mood-related symptoms. Survey results suggest moderate to high levels of satisfaction for the treatment from patients and therapists. A new scale, the Borderline Evaluation of Severity Over Time (BEST), developed to measure severity and change in persons with BPD, is described. We propose to conduct additional research to further validate the efficacy of STEPPS.

The borderline diagnosis I: psychopathology, comorbidity, and personality structure.

Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.

The borderline diagnosis II: biology, genetics, and clinical course.

In Part I of this three-part article, consideration of the core features of BPD psychopathology, of comorbidity with Axis I disorders, and of underlying personality trait structure suggested that the borderline diagnosis might be productively studied from the perspective of dimensions of trait expression, in addition to that of the category itself. In Part II, we review the biology, genetics, and clinical course of borderline personality disorder (BPD), continuing to attend to the utility of a focus on fundamental dimensions of psychopathology. Biological approaches to the study of personality can identify individual differences with both genetic and environmental influences. The aspects of personality disorder that are likely to have biologic correlates are those involving regulation of affects, impulse/action patterns, cognitive organization and anxiety/inhibition. For BPD, key psychobiological domains include impulsive aggression, associated with reduced serotonergic activity in the brain, and affective instability, associated with increased responsivity of cholinergic systems. There may be a strong genetic component for the development of BPD, but it seems clear, at least, that there are strong genetic influences on traits that underlie it, such as neuroticism, impulsivity, anxiousness, affective lability, and insecure attachment. The course of BPD suggests a heterogeneous disorder. Predictors of poor prognosis include history of childhood sexual abuse, early age at first psychiatric contact, chronicity of symptoms, affective instability, aggression, substance abuse, and increased comorbidity. For research purposes, at least, biological, genetic, and prognostic studies all continue to suggest the need to supplement categorical diagnoses of BPD with assessments of key underlying personality trait dimensions and with historical and clinical observations apart from those needed to make the borderline diagnosis itself.

Outcome Following Electroconvulsive Therapy: A Comparison of Primary and Secondary Depression.

In a consecutive series of 117 depressed patients referred for electroconvulsive therapy, the 10 with secondary depression had significantly poorer outcomes according to three independently assessed measures-Hamilton rating scale score at discharge, global rating at discharge, and mean depressive symptom score during a 6-month follow-up.