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.     

An exploratory study of the relationship between changes in emotion and cognitive processes and treatment outcome in borderline personality disorder

Abstract

This exploratory study examined specific emotion processes and cognitive problem-solving processes in individuals with borderline personality disorder (BPD), and assessed the relationship of these changes to treatment outcome. Emotion and cognitive problem-solving processes were assessed using the Toronto Alexithymia Scale, the Linguistic Inquiry Word Count, the Derogatis Affect Balance Scale, and the Problem Solving Inventory. Participants who showed greater improvements in affect balance, problem solving, and the ability to identify and describe emotions showed greater improvements on treatment outcome, with affect balance remaining statistically significant under the most conservative conditions. The results provide preliminary evidence to support the theory that specific improvements in emotion and cognitive processes are associated with positive treatment outcomes (symptom distress, interpersonal functioning) in BPD. The implications for treatment are discussed.     

Systems Training for Emotional Predictability and Problem Solving (STEPPS): Program efficacy and personality features as predictors of drop-out — An Italian study

In this study we present a clinical application of the STEPPS model in an Italian sample of severely affected patients with borderline personality disorder (BPD) or personality disorder (PD) with prominent borderline features in comorbidity with a mood disorder. The aims of this work are: 1) to confirm our preliminary results in a larger sample and at a 12-month follow-up, and 2) to identify predictors of drop-out vs completion of STEPPS in order to understand which characteristics of patients make them suitable or not for this treatment. The sample is composed of 32 subjects recruited from a population of inpatients of the Mood Disorders Center, Department of Clinical Neurosciences, Hospital San Raffaele-Turro, Milan. To confirm STEPPS efficacy at 12-month follow-up, we selected the following outcome criteria: reduction in the number of hospitalizations related to self-harm acts; reduction in the number of suicidal attempts; reduction of perceived emotional intensity levels; changes in cognitive filter scores; changes in the scores on self-report questionnaires. To identify predictors of drop-out vs completion, we analysed the following variables: demographic features (sex, marital status, school level achieved, and job status); Axis-I diagnosis; Axis-II categorical and dimensional diagnosis; and personality features. Seventeen (53%) subjects completed the treatment successfully. The drop-out rate was 47%. Patients who completed the program show a significant decrease in the number of hospitalizations, both at the end of the treatment and at 12-month follow-up. Friedman ANOVA test shows a significant decrease in suicidal attempts during and after STEPPS, and at 12-month follow-up. Analysis of drop-outs showed no significant differences with regard to sex, marital status, school level and job status between the two groups. Axis-I and Axis-II categorical diagnoses did not discriminate between the two groups. Those patients who dropped differ significantly from completers in histrionic personality traits and magical thinking index, given by the interaction between low scores in Self-Directedness and high scores in Self-Transcendence.     

The course of dissociation for patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study

Objective: The purpose of this study was to assess the severity of dissociation reported by borderline patients and axis II comparison subjects over 10 years of prospective follow‐up. Method: The Dissociative Experiences Scale (DES) – a 28‐item self‐report measure – was administered to 290 borderline in‐patients and 72 axis II comparison subjects during their index admission. It was also re‐administered at five contiguous 2‐year follow‐up periods. Results: The overall severity of dissociative experiences of those in both study groups decreased significantly over time but was discernibly greater in borderline patients (61% vs. 43%). The same pattern emerged for the subtypes of dissociation that were studied: absorption, depersonalization and amnesia. Conclusion: The severity of dissociation declines significantly over time for even severely ill borderline patients. However, it remains as a recurring problem for over a third of those with DES scores that initially were in the range associated with trauma‐spectrum disorders.     

Psychosocial predictors of treatment response to cognitive-behavior therapy for late-life depression: an exploratory study

Objective: The primary objective of this study was to examine a variety of potential predictors of response to Cognitive Behavioral Therapy (CBT) in depressed older adults.

Method: Sixty older adults with a clinical diagnosis of major or minor depression or dysthymic disorder received 12 individual sessions of CBT over a three- to four-month-period. The BDI-II was administered pre- and post-intervention to assess change in the level of depression. A cutoff score of 13 or less at post was used to determine positive treatment response. A variety of measures (obtained at baseline) were evaluated using hierarchical regression techniques to predict improvement following treatment.

Results: Individuals who showed greater improvement were: (a) more open to new experiences; (b) less negatively affected by past stressors; (c) less inclined to have an external locus of control but more likely to cite others as responsible for negative stress in their lives; and (d) were more likely to seek emotional support when symptomatic. Lower education level and reported use of active coping strategies at baseline were associated with less improvement. Other variables (e.g., age, overall physical health, and cognitive status) were not associated with treatment response. Use of logistic regression to predict responders vs. nonresponders yielded a similar pattern.

Conclusion: These findings agree with prior research confirming the effectiveness of a brief CBT intervention for older depressed persons and suggest further exploration of several psychosocial factors that may contribute to a stronger response to CBT.     

Sequential cognitive-behavioral therapy for children with obsessive-compulsive disorder with an inadequate medication response: a case series of five patients

Few data have been reported on the efficacy of cognitive-behavioral therapy (CBT) for youth with obsessive-compulsive disorder (OCD) who have not responded to prior treatment with medication. Given this, we report an open trial of CBT for children who have remained symptomatic following medication trials. Five children with OCD who had an inadequate response to psychotropic medications (e.g., limited response and/or unable to be titrated to a complete dose due to side effects) received treatment in a 3-week intensive CBT program. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (much improved or very much improved) and the severity of clinician-rated OCD symptoms and impairment significantly decreased after the intervention. Although a number of limitations of this preliminary report exist, this study provides preliminary support for the utility of an intensive intervention for youth with OCD who have had an inadequate response and/or adverse side effects.     

Electroconvulsive therapy for depression with comorbid borderline personality disorder or post-traumatic stress disorder: A matched retrospective cohort study

Background

The impact of comorbid borderline personality disorder (BPD) or post-traumatic stress disorder (PTSD) on clinical and cognitive outcomes of electroconvulsive therapy (ECT) in patients with major depressive episodes (MDE) is unknown.

Yi-gan san for the treatment of borderline personality disorder: an open-label study

BACKGROUND: Numerous medications have been tested on patients with borderline personality disorder (BPD). Although many of these medications have been demonstrated to be useful, no clear main treatment for BPD has emerged. Despite the efficacy of some of the medicines, acceptability and side effects have proven to be barriers to their use. Recent studies indicate that the traditional Chinese herbal medicine yi-gan san (YGS, yokukan-san in Japanese) may be safe and useful in treating behavioral and psychological symptoms in dementia patients. We aimed at evaluating both efficacy and safety of yi-gan san in patients with well-defined BPD. METHODS: Twenty female outpatients diagnosed with BPD according to DSM-IV criteria and the revised Diagnostic Interview for Borderlines completed a 12-week open-label study with yi-gan san at an average daily dosage of 6.4+/-1.9 g (2.5-7.5 g). Psychometric instruments to assess efficacy included the Brief Psychiatric Rating Scale (BPRS), Hamilton Rating Scales for Depression (HAM-D), Global Assessment of Functioning (GAF), Clinical Global Impression Scale (CGI), and Aggression Questionnaire (AQ). RESULTS: Most psychometric scale scores exhibited a highly significant improvement (total BPRS; BPRS somatic concern, anxiety, tension, depressive mood, hostility, suspiciousness, motor retardation, uncooperativeness, and excitement subscale; CGI; GAF; AQ) over time. CONCLUSIONS: In this open-label pilot study, patients treated with YGS showed statistically significant reduction on self-rated and clinician-rated scales. The present findings suggest that yi-gan san might be effective for the treatment of a number of BPD symptoms, including low mood, impulsivity, and aggression.     

The catechol o‐methyltransferase (COMT) val158met polymorphism modulates the association of serious life events (SLE) and impulsive aggression in female patients with borderline personality disorder (BPD)

Wagner S, Baskaya Ö, Anicker NJ, Dahmen N, Lieb K, Tadi? A. The catechol o‐methyltransferase (COMT) val¹⁵⁸met polymorphism modulates the association of serious life events (SLE) and impulsive aggression in female patients with borderline personality disorder (BPD). Objective: We analyzed i) the effects of serious life events (SLE) on impulsive aggression, and ii) modulating effects of the COMT Val¹⁵⁸Met polymorphism on the association between SLEs and impulsive aggression in borderline personality disorder (BPD). Method: One hundred and twelve female BPD patients from Germany were included in this study. Impulsive aggression was assessed by the Buss‐Durkee‐Hostility Inventory (BDHI). Results: Childhood sexual abuse was associated with lower BDHI sum score (P = 0.003). In COMT Val¹⁵⁸Val carriers, but not in Val/Met and Met/Met carriers, childhood sexual abuse and the cumulative number of SLEs were associated with lower BDHI sum scores (P < 0.05). Conclusion: This study analyzing a specific gene × environment interaction in female BPD patients suggests an association between SLEs and impulsive aggression, as well as a modulating effect of the COMT Val¹⁵⁸Val genotype on the relation between SLEs and impulsive aggression.     

Borderline personality features and development of psychosis in an 'ultra high risk' (UHR) population: a case control study

Aims: There is clinical uncertainty as to whether borderline personality disorder (BPD) traits in those with an ‘at risk mental state’ have an effect on the risk of ‘transition’ to psychosis. We aimed to investigate the relationship between baseline BPD features, risk of transition and type of psychotic disorder experienced. Method: This is a case‐control study of ‘Ultra High Risk’ (UHR) for psychosis patients treated at the clinic, between 2004 and 2007. ‘Cases’ were UHR individuals who made the ‘transition’ to full threshold psychotic disorder within 24 months; ‘Control’ group was a matched UHR sample who had not developed a psychotic disorder at 24 months. Individuals were matched on time of entry to the clinic, age and gender. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) BPD features were assessed from clinical assessments using a structured instrument (Structured Clinical Interview for DSM‐IV Axis II Disorder for BPD (SCID‐II BPD) ). Psychosis diagnosis following transition was rated from the clinical files using the operational criteria in studies of psychotic illness (OPCRIT) computer algorithm. The number of BPD traits and number with full threshold BPD were compared in those who developed psychosis and those who did not. Results: We analysed data from 48 cases and 48 controls. There was no statistically significant difference in the rate of transition to psychosis for those with baseline full‐threshold BPD, compared with those without BPD. The number of BPD traits or number with full threshold BPD did not differ by psychosis diagnosis grouping. Conclusions: Co‐occurring BPD or BPD features does not appear to strongly influence the risk of short‐term transition to psychosis or the risk of developing a non‐affective psychotic disorder in this population.     

Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs

Background: Exposure and response prevention (ERP) for obsessive–compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low‐intensity, low‐cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention. Methods: Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low‐intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist‐administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist‐administered ERP with no lower‐intensity lead‐in. Results: The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third‐party payers than did standard ERP, with large effect sizes. Conclusions: These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long‐term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings. Depression and Anxiety 0:1–10, 2011. © 2011 Wiley‐Liss, Inc.