Treating borderline personality disorder can seem like a no-win situation. If we try traditional cognitive-behavioral therapy (CBT) and emphasize change, patients feel unheard and invalidated; they may withdraw, quit, or even attack. But if we suggest ways to accept unhappy situations, they may feel we don’t understand their suffering.

A more effective approach is dialectical behavior therapy (DBT), first developed to treat highly suicidal persons with borderline personality disorder and used with other populations that have difficulty regulating their emotions.

This article describes how invalidating environments may damage emotional health and suggests how psychiatrists can use DBT’s methods when treating borderline personality disorder.

BIOLOGY PLUS ENVIRONMENT

For the patient, borderline personality disorder’s behavior clusters (Table 1):

• function to regulate emotions
• or result from emotion dysregulation.

DBT theory identifies emotion dysregulation as the primary deficit in borderline personality disorder. Biologically based emotional vulnerability is seen as interacting with an inability to modulate emotions because of a skills deficit.

Emotional vulnerability. Three characteristics—high sensitivity, high reactivity, and slow return to baseline emotional state—define high emotional vulnerability:

High sensitivity. The person reacts more quickly and to more things than do others in emotion-provoking situations. When walking, for example, they may pass someone who doesn’t say hello. Most people would shrug this off, but persons with high emotional sensitivity may quickly notice, assume there is a problem, feel they have done something wrong, then feel shame and anger.

High reactivity. Their emotional reactions are large, and the high arousal dysregulates cognitive processing.

Slow return to baseline. Events stack up because emotional reactions are long-lasting for persons with high emotional vulnerability. They don’t have time to get over one thing before something else happens.

DBT postulates that, over time, borderline personality disorder results from the transaction of biological emotional vulnerability and an invalidating environment. This therapeutic model asserts that biology and the environment are flexible, and interventions may influence both.

Invalidating environment. DBT acknowledges that invalidation occurs in all environments, even nuturing ones. It becomes detrimental when a vulnerable person is exposed to pervasive invalidation that is not related to the validity of the person’s behavior or to the person’s expressed emotions or thoughts.

An invalidating environment has three characteristic patterns. One is indiscriminate rejection of communication of private experiences and self-generated behaviors.

Case examples. Mary, age 8, says she’s been teased and it hurt her feelings. Her mother tells her she is making too much of the incident. Mary questions herself and searches the social environment for cues about how to respond to similar situations in the future.

Robbie, age 4, completes a drawing and shows it to his father with delight. His father points out some “sloppy” coloring. If his father repeatedly finds fault with his work, Robbie is likely to not show him his work or stop drawing, and his expressions of delight are likely to decrease.

Invalidating environments may also punish emotional displays and intermittently reinforce emotional escalation. Someone may show disapproval for or ignore a person’s genuine sadness or fear but attend to angry outbursts that result when the person feels ignored.

The third invalidating pattern is to oversimplify the ease of problem-solving and meeting goals.

Case example. As a child, when Susan asked for help, her mother would say “just do it,” without considering the skills her daughter needed to accomplish tasks. When Susan became frustrated, her mother demanded that she “just stop cying,” even though no person could modulate his or her emotions that quickly. As an adult, Susan now sets unrealistic goals and expectations for herself and despairs when she is unable to solve problems in her life.

These three invalidating patterns cause persons to search the social environment for cues about how to respond to situations. They may question themselves, their identity, and the appropriateness of any emotional expression. As a result, they may oscillate between emotional inhibition and extreme emotional styles, set unrealistic goals and expectations for themselves, and eventually despair of being able to solve their problems.

Specific to borderline personality disorder is that the environment ignores genuine emotional expression, and the individual’s emotions escalate. This pattern is reinforced when the listener finally rewards emotionally extreme behavior with attention or desired changes.

As the pattern is repeated over time, extreme emotional reactions become the norm rather than the exception, and the emotional chaos can make the person wish to die. Acting on that desire when past expressions of desperation have been ignored or invalidated can provide attention or interventions that would never happen after simple emotional expressions.

Thus, an environment that does not recognize or validate genuine emotional expression can reinforce suicidality.

Table 1

Diagnostic criteria for borderline personality disorder

SOLVING NO-WIN THERAPY

Pitfalls with emphasizing change. Therapy that emphasizes solving problems and getting things to change typically triggers high arousal in persons with borderline personality disorder. Feeling out of control, they respond by trying to get in control, including attempts to control the therapist.

Similarly, they see attempts to get them to change their behavior as invalidating their experiences or, worse, who they are. Intense emotions aroused by the message they hear—that they are the source of their problems—impair learning and intensify their efforts to gain control. In a battle for control, collaboration and therapy cannot occur.

Case example. Ms. K wants you to understand how difficult her life is because of difficulties with her boss. You start talking about what Ms. K can do to change the situation, without acknowledging how difficult it is to deal with her boss.

Ms. K feels upset and says you don’t understand. For her, the interaction has led to emotion dysregulation and impaired cognitive processing.

Pitfalls with emphasizing acceptance. Most persons who come to therapy very distressed want something in their lives to change. If your primary message is acceptance instead of change, they may lose confidence in you.

Case example. Ms. K wants help dealing with her boss, who is making life quite difficult. As her therapist, you respond with warmth and acceptance but offer no suggestions as to how she might change the situation. Ms. K likes the way you listen to her but abandons therapy. after several sessions.

At first, patients with borderline personality disorder may like the warmth of client-centered acceptance approaches. Over time, however, they may feel their therapy sessions are out of control. They may think the therapist doesn’t understand the situation, doesn’t know how to help, or that situations that are troubling them cannot be changed.

Balanced therapy. DBT solves the change-or-acceptance dilemma by attempting to help patients with borderline personality disorder change themselves and their lives while offering strategies for accepting themselves and their situations.^1,2 DBT includes problem-solving and acceptance strategies (Table 2).

Table 2

Strategies used in dialectical behavioral therapy

DBT’S 4 THERAPY STAGES

DBT is a comprehensive treatment. The original outpatient model for borderline personality disorder (Table 3) has been adapted to different settings and applied to other populations.

Outpatients meet weekly in individual psychotherapy and a skills training group.³ Therapists also meet weekly in a consultation team viewed as “therapy for the therapist.”

Between sessions, therapists consult with patients by telephone to:

• decrease suicide crisis behaviors
• increase generalization of behavioral skills
• decrease patients’ feelings of conflict, alienation, or distance with the therapist.

Four stages. DBT follows four stages. For persons with borderline personality disorder, researchers have evaluated the efficacy of stage-1 therapy. Studies on stage-3 DBT have been conducted with nonborderline-personality individuals with eating disorders. The goals at each stage are:

Stage 1. Move from severe behavioral dyscontrol to behavioral control. Decrease suicidal and other life-threatening behaviors and those that interfere with therapy and quality of life. Increase mindfulness, tolerance for distress, interpersonal effectiveness, and emotion regulation.

Stage 2. Move from quiet desperation to emotional experiencing.

Stage 3. Address problems in living, and move toward ordinary happiness/unhappiness.

Stage 4. Move from incompleteness to capacity for joy and freedom.

Seven randomized controlled trials have shown that DBT can be useful in treating borderline personality disorder.^4-10 The initial trial by Linehan et al⁴ included 47 women ages 18 to 45 who met criteria for borderline personality disorder and had at least two parasuicide incidents in the previous 5 years, with one in the previous 8 weeks. Treatment lasted 1 year, and subjects agreed to stop other individual psychotherapy if assigned to DBT.

Subjects were then randomly assigned to either DBT or “treatment as usual” in the community. In the various DBT studies, treatment-as-usual has included community therapists, Department of Veterans Affairs outpatient treatment, client-centered therapy, and treatment by persons identified by their peers as experts in their communities.

Subjects were assessed every 4 months while in treatment and for 1 year thereafter. DBT was more effective than usual treatment in:

• reducing suicide attempts and self-injury
• decreasing premature dropout from therapy
• reducing emergency room admissions and length of psychiatric hospitalization
• reducing drug abuse, depression, hopelessness, and anger.

Table 3

Modes of therapy in outpatient dialectical behavioral therapy

RECOMMENDATIONS

Some psychiatrists may find “borderline patients” frustrating and unpleasant to treat. DBT therapists, however, make two assumptions that can help anyone working with individuals with borderline personality disorder. To avoid falling into the trap of polarization with these patients, assume that:

• they are doing the best they can
• their efforts are insufficient to meet their needs.

They therefore need to do better, and the therapist’s job is to help them do so. Also assume that if you try to help a patient with borderline personality disorder, you will need help, too. We require DBT therapists to participate in consultation teams.

Training. DBT is a comprehensive program that requires familiarity with the manuals mentioned in this article (see Related resources). Some teams have learned DBT through self-study and consultation with other teams.

If you plan to offer DBT to patients with borderline personality disorder, we recommend that you be:

• trained in behavior therapy and CBT
• familiar with research on emotions and processes involved in emotion regulation.

If you have not had CBT training, find a behavior therapist to join your team or get consultation from a behavior therapist.

An intensive training course in DBT—with 2 weeks of instruction and case consultation and several months of consultation with someone well-versed in DBT—is an efficient way to become familiar with the most critical principles of the treatment. If you cannot train toward adherent delivery of individual therapy, we recommend referring patients to someone trained in DBT.

Related resources

• Lieb K, Zanarini MC, Schmahl C, et al. Borderline personality disorder. Lancet 2004;364(9432):453-61.
• University of Washington, Behavioral Research and Therapy Clinics. www.brtc.psych.washington.edu/frameResearch.htm;
  www.brtc.psych.washington.edu/framePublications.htm
• Behavioral Tech, LLC. Consultation and training in dialectical behavioral therapy. www.behavioraltech.org.

Disclosures

Dr. DuBose is president and CEO/co-owner of DBT Center of Seattle, PLLC, and a speaker for Behavioral Tech, LLC.

Dr. Linehan is a shareholder in Behavioral Tech Research, Inc., which develops computerized training for DBT, a DBT trainer for Behavioral Tech, LLC, and the author of two books on DBT. She also receives research grants from the National Institute of Mental Health and National Institute on Drug Abuse.

Treating borderline personality disorder can seem like a no-win situation. If we try traditional cognitive-behavioral therapy (CBT) and emphasize change, patients feel unheard and invalidated; they may withdraw, quit, or even attack. But if we suggest ways to accept unhappy situations, they may feel we don’t understand their suffering.

A more effective approach is dialectical behavior therapy (DBT), first developed to treat highly suicidal persons with borderline personality disorder and used with other populations that have difficulty regulating their emotions.

This article describes how invalidating environments may damage emotional health and suggests how psychiatrists can use DBT’s methods when treating borderline personality disorder.

BIOLOGY PLUS ENVIRONMENT

For the patient, borderline personality disorder’s behavior clusters (Table 1):

• function to regulate emotions
• or result from emotion dysregulation.

DBT theory identifies emotion dysregulation as the primary deficit in borderline personality disorder. Biologically based emotional vulnerability is seen as interacting with an inability to modulate emotions because of a skills deficit.

Emotional vulnerability. Three characteristics—high sensitivity, high reactivity, and slow return to baseline emotional state—define high emotional vulnerability:

High sensitivity. The person reacts more quickly and to more things than do others in emotion-provoking situations. When walking, for example, they may pass someone who doesn’t say hello. Most people would shrug this off, but persons with high emotional sensitivity may quickly notice, assume there is a problem, feel they have done something wrong, then feel shame and anger.

High reactivity. Their emotional reactions are large, and the high arousal dysregulates cognitive processing.

Slow return to baseline. Events stack up because emotional reactions are long-lasting for persons with high emotional vulnerability. They don’t have time to get over one thing before something else happens.

DBT postulates that, over time, borderline personality disorder results from the transaction of biological emotional vulnerability and an invalidating environment. This therapeutic model asserts that biology and the environment are flexible, and interventions may influence both.

Invalidating environment. DBT acknowledges that invalidation occurs in all environments, even nuturing ones. It becomes detrimental when a vulnerable person is exposed to pervasive invalidation that is not related to the validity of the person’s behavior or to the person’s expressed emotions or thoughts.

An invalidating environment has three characteristic patterns. One is indiscriminate rejection of communication of private experiences and self-generated behaviors.

Case examples. Mary, age 8, says she’s been teased and it hurt her feelings. Her mother tells her she is making too much of the incident. Mary questions herself and searches the social environment for cues about how to respond to similar situations in the future.

Robbie, age 4, completes a drawing and shows it to his father with delight. His father points out some “sloppy” coloring. If his father repeatedly finds fault with his work, Robbie is likely to not show him his work or stop drawing, and his expressions of delight are likely to decrease.

Invalidating environments may also punish emotional displays and intermittently reinforce emotional escalation. Someone may show disapproval for or ignore a person’s genuine sadness or fear but attend to angry outbursts that result when the person feels ignored.

The third invalidating pattern is to oversimplify the ease of problem-solving and meeting goals.

Case example. As a child, when Susan asked for help, her mother would say “just do it,” without considering the skills her daughter needed to accomplish tasks. When Susan became frustrated, her mother demanded that she “just stop cying,” even though no person could modulate his or her emotions that quickly. As an adult, Susan now sets unrealistic goals and expectations for herself and despairs when she is unable to solve problems in her life.

These three invalidating patterns cause persons to search the social environment for cues about how to respond to situations. They may question themselves, their identity, and the appropriateness of any emotional expression. As a result, they may oscillate between emotional inhibition and extreme emotional styles, set unrealistic goals and expectations for themselves, and eventually despair of being able to solve their problems.

Specific to borderline personality disorder is that the environment ignores genuine emotional expression, and the individual’s emotions escalate. This pattern is reinforced when the listener finally rewards emotionally extreme behavior with attention or desired changes.

As the pattern is repeated over time, extreme emotional reactions become the norm rather than the exception, and the emotional chaos can make the person wish to die. Acting on that desire when past expressions of desperation have been ignored or invalidated can provide attention or interventions that would never happen after simple emotional expressions.

Thus, an environment that does not recognize or validate genuine emotional expression can reinforce suicidality.

Table 1

Diagnostic criteria for borderline personality disorder

SOLVING NO-WIN THERAPY

Pitfalls with emphasizing change. Therapy that emphasizes solving problems and getting things to change typically triggers high arousal in persons with borderline personality disorder. Feeling out of control, they respond by trying to get in control, including attempts to control the therapist.

Similarly, they see attempts to get them to change their behavior as invalidating their experiences or, worse, who they are. Intense emotions aroused by the message they hear—that they are the source of their problems—impair learning and intensify their efforts to gain control. In a battle for control, collaboration and therapy cannot occur.

Case example. Ms. K wants you to understand how difficult her life is because of difficulties with her boss. You start talking about what Ms. K can do to change the situation, without acknowledging how difficult it is to deal with her boss.

Ms. K feels upset and says you don’t understand. For her, the interaction has led to emotion dysregulation and impaired cognitive processing.

Pitfalls with emphasizing acceptance. Most persons who come to therapy very distressed want something in their lives to change. If your primary message is acceptance instead of change, they may lose confidence in you.

Case example. Ms. K wants help dealing with her boss, who is making life quite difficult. As her therapist, you respond with warmth and acceptance but offer no suggestions as to how she might change the situation. Ms. K likes the way you listen to her but abandons therapy. after several sessions.

At first, patients with borderline personality disorder may like the warmth of client-centered acceptance approaches. Over time, however, they may feel their therapy sessions are out of control. They may think the therapist doesn’t understand the situation, doesn’t know how to help, or that situations that are troubling them cannot be changed.

Balanced therapy. DBT solves the change-or-acceptance dilemma by attempting to help patients with borderline personality disorder change themselves and their lives while offering strategies for accepting themselves and their situations.^1,2 DBT includes problem-solving and acceptance strategies (Table 2).

Table 2

Strategies used in dialectical behavioral therapy

DBT’S 4 THERAPY STAGES

DBT is a comprehensive treatment. The original outpatient model for borderline personality disorder (Table 3) has been adapted to different settings and applied to other populations.

Outpatients meet weekly in individual psychotherapy and a skills training group.³ Therapists also meet weekly in a consultation team viewed as “therapy for the therapist.”

Between sessions, therapists consult with patients by telephone to:

• decrease suicide crisis behaviors
• increase generalization of behavioral skills
• decrease patients’ feelings of conflict, alienation, or distance with the therapist.

Four stages. DBT follows four stages. For persons with borderline personality disorder, researchers have evaluated the efficacy of stage-1 therapy. Studies on stage-3 DBT have been conducted with nonborderline-personality individuals with eating disorders. The goals at each stage are:

Stage 1. Move from severe behavioral dyscontrol to behavioral control. Decrease suicidal and other life-threatening behaviors and those that interfere with therapy and quality of life. Increase mindfulness, tolerance for distress, interpersonal effectiveness, and emotion regulation.

Stage 2. Move from quiet desperation to emotional experiencing.

Stage 3. Address problems in living, and move toward ordinary happiness/unhappiness.

Stage 4. Move from incompleteness to capacity for joy and freedom.

Seven randomized controlled trials have shown that DBT can be useful in treating borderline personality disorder.^4-10 The initial trial by Linehan et al⁴ included 47 women ages 18 to 45 who met criteria for borderline personality disorder and had at least two parasuicide incidents in the previous 5 years, with one in the previous 8 weeks. Treatment lasted 1 year, and subjects agreed to stop other individual psychotherapy if assigned to DBT.

Subjects were then randomly assigned to either DBT or “treatment as usual” in the community. In the various DBT studies, treatment-as-usual has included community therapists, Department of Veterans Affairs outpatient treatment, client-centered therapy, and treatment by persons identified by their peers as experts in their communities.

Subjects were assessed every 4 months while in treatment and for 1 year thereafter. DBT was more effective than usual treatment in:

• reducing suicide attempts and self-injury
• decreasing premature dropout from therapy
• reducing emergency room admissions and length of psychiatric hospitalization
• reducing drug abuse, depression, hopelessness, and anger.

Table 3

Modes of therapy in outpatient dialectical behavioral therapy

RECOMMENDATIONS

Some psychiatrists may find “borderline patients” frustrating and unpleasant to treat. DBT therapists, however, make two assumptions that can help anyone working with individuals with borderline personality disorder. To avoid falling into the trap of polarization with these patients, assume that:

• they are doing the best they can
• their efforts are insufficient to meet their needs.

They therefore need to do better, and the therapist’s job is to help them do so. Also assume that if you try to help a patient with borderline personality disorder, you will need help, too. We require DBT therapists to participate in consultation teams.

Training. DBT is a comprehensive program that requires familiarity with the manuals mentioned in this article (see Related resources). Some teams have learned DBT through self-study and consultation with other teams.

If you plan to offer DBT to patients with borderline personality disorder, we recommend that you be:

• trained in behavior therapy and CBT
• familiar with research on emotions and processes involved in emotion regulation.

If you have not had CBT training, find a behavior therapist to join your team or get consultation from a behavior therapist.

An intensive training course in DBT—with 2 weeks of instruction and case consultation and several months of consultation with someone well-versed in DBT—is an efficient way to become familiar with the most critical principles of the treatment. If you cannot train toward adherent delivery of individual therapy, we recommend referring patients to someone trained in DBT.

Related resources

• Lieb K, Zanarini MC, Schmahl C, et al. Borderline personality disorder. Lancet 2004;364(9432):453-61.
• University of Washington, Behavioral Research and Therapy Clinics. www.brtc.psych.washington.edu/frameResearch.htm;
  www.brtc.psych.washington.edu/framePublications.htm
• Behavioral Tech, LLC. Consultation and training in dialectical behavioral therapy. www.behavioraltech.org.

Disclosures

Dr. DuBose is president and CEO/co-owner of DBT Center of Seattle, PLLC, and a speaker for Behavioral Tech, LLC.

Dr. Linehan is a shareholder in Behavioral Tech Research, Inc., which develops computerized training for DBT, a DBT trainer for Behavioral Tech, LLC, and the author of two books on DBT. She also receives research grants from the National Institute of Mental Health and National Institute on Drug Abuse.

Treating borderline personality disorder can seem like a no-win situation. If we try traditional cognitive-behavioral therapy (CBT) and emphasize change, patients feel unheard and invalidated; they may withdraw, quit, or even attack. But if we suggest ways to accept unhappy situations, they may feel we don’t understand their suffering.

A more effective approach is dialectical behavior therapy (DBT), first developed to treat highly suicidal persons with borderline personality disorder and used with other populations that have difficulty regulating their emotions.

This article describes how invalidating environments may damage emotional health and suggests how psychiatrists can use DBT’s methods when treating borderline personality disorder.

BIOLOGY PLUS ENVIRONMENT

For the patient, borderline personality disorder’s behavior clusters (Table 1):

• function to regulate emotions
• or result from emotion dysregulation.

DBT theory identifies emotion dysregulation as the primary deficit in borderline personality disorder. Biologically based emotional vulnerability is seen as interacting with an inability to modulate emotions because of a skills deficit.

Emotional vulnerability. Three characteristics—high sensitivity, high reactivity, and slow return to baseline emotional state—define high emotional vulnerability:

High sensitivity. The person reacts more quickly and to more things than do others in emotion-provoking situations. When walking, for example, they may pass someone who doesn’t say hello. Most people would shrug this off, but persons with high emotional sensitivity may quickly notice, assume there is a problem, feel they have done something wrong, then feel shame and anger.

High reactivity. Their emotional reactions are large, and the high arousal dysregulates cognitive processing.

Slow return to baseline. Events stack up because emotional reactions are long-lasting for persons with high emotional vulnerability. They don’t have time to get over one thing before something else happens.

DBT postulates that, over time, borderline personality disorder results from the transaction of biological emotional vulnerability and an invalidating environment. This therapeutic model asserts that biology and the environment are flexible, and interventions may influence both.

Invalidating environment. DBT acknowledges that invalidation occurs in all environments, even nuturing ones. It becomes detrimental when a vulnerable person is exposed to pervasive invalidation that is not related to the validity of the person’s behavior or to the person’s expressed emotions or thoughts.

An invalidating environment has three characteristic patterns. One is indiscriminate rejection of communication of private experiences and self-generated behaviors.

Case examples. Mary, age 8, says she’s been teased and it hurt her feelings. Her mother tells her she is making too much of the incident. Mary questions herself and searches the social environment for cues about how to respond to similar situations in the future.

Robbie, age 4, completes a drawing and shows it to his father with delight. His father points out some “sloppy” coloring. If his father repeatedly finds fault with his work, Robbie is likely to not show him his work or stop drawing, and his expressions of delight are likely to decrease.

Invalidating environments may also punish emotional displays and intermittently reinforce emotional escalation. Someone may show disapproval for or ignore a person’s genuine sadness or fear but attend to angry outbursts that result when the person feels ignored.

The third invalidating pattern is to oversimplify the ease of problem-solving and meeting goals.

Case example. As a child, when Susan asked for help, her mother would say “just do it,” without considering the skills her daughter needed to accomplish tasks. When Susan became frustrated, her mother demanded that she “just stop cying,” even though no person could modulate his or her emotions that quickly. As an adult, Susan now sets unrealistic goals and expectations for herself and despairs when she is unable to solve problems in her life.

These three invalidating patterns cause persons to search the social environment for cues about how to respond to situations. They may question themselves, their identity, and the appropriateness of any emotional expression. As a result, they may oscillate between emotional inhibition and extreme emotional styles, set unrealistic goals and expectations for themselves, and eventually despair of being able to solve their problems.

Specific to borderline personality disorder is that the environment ignores genuine emotional expression, and the individual’s emotions escalate. This pattern is reinforced when the listener finally rewards emotionally extreme behavior with attention or desired changes.

As the pattern is repeated over time, extreme emotional reactions become the norm rather than the exception, and the emotional chaos can make the person wish to die. Acting on that desire when past expressions of desperation have been ignored or invalidated can provide attention or interventions that would never happen after simple emotional expressions.

Thus, an environment that does not recognize or validate genuine emotional expression can reinforce suicidality.

Table 1

Diagnostic criteria for borderline personality disorder

SOLVING NO-WIN THERAPY

Pitfalls with emphasizing change. Therapy that emphasizes solving problems and getting things to change typically triggers high arousal in persons with borderline personality disorder. Feeling out of control, they respond by trying to get in control, including attempts to control the therapist.

Similarly, they see attempts to get them to change their behavior as invalidating their experiences or, worse, who they are. Intense emotions aroused by the message they hear—that they are the source of their problems—impair learning and intensify their efforts to gain control. In a battle for control, collaboration and therapy cannot occur.

Case example. Ms. K wants you to understand how difficult her life is because of difficulties with her boss. You start talking about what Ms. K can do to change the situation, without acknowledging how difficult it is to deal with her boss.

Ms. K feels upset and says you don’t understand. For her, the interaction has led to emotion dysregulation and impaired cognitive processing.

Pitfalls with emphasizing acceptance. Most persons who come to therapy very distressed want something in their lives to change. If your primary message is acceptance instead of change, they may lose confidence in you.

Case example. Ms. K wants help dealing with her boss, who is making life quite difficult. As her therapist, you respond with warmth and acceptance but offer no suggestions as to how she might change the situation. Ms. K likes the way you listen to her but abandons therapy. after several sessions.

At first, patients with borderline personality disorder may like the warmth of client-centered acceptance approaches. Over time, however, they may feel their therapy sessions are out of control. They may think the therapist doesn’t understand the situation, doesn’t know how to help, or that situations that are troubling them cannot be changed.

Balanced therapy. DBT solves the change-or-acceptance dilemma by attempting to help patients with borderline personality disorder change themselves and their lives while offering strategies for accepting themselves and their situations.^1,2 DBT includes problem-solving and acceptance strategies (Table 2).

Table 2

Strategies used in dialectical behavioral therapy

DBT’S 4 THERAPY STAGES

DBT is a comprehensive treatment. The original outpatient model for borderline personality disorder (Table 3) has been adapted to different settings and applied to other populations.

Outpatients meet weekly in individual psychotherapy and a skills training group.³ Therapists also meet weekly in a consultation team viewed as “therapy for the therapist.”

Between sessions, therapists consult with patients by telephone to:

• decrease suicide crisis behaviors
• increase generalization of behavioral skills
• decrease patients’ feelings of conflict, alienation, or distance with the therapist.

Four stages. DBT follows four stages. For persons with borderline personality disorder, researchers have evaluated the efficacy of stage-1 therapy. Studies on stage-3 DBT have been conducted with nonborderline-personality individuals with eating disorders. The goals at each stage are:

Stage 1. Move from severe behavioral dyscontrol to behavioral control. Decrease suicidal and other life-threatening behaviors and those that interfere with therapy and quality of life. Increase mindfulness, tolerance for distress, interpersonal effectiveness, and emotion regulation.

Stage 2. Move from quiet desperation to emotional experiencing.

Stage 3. Address problems in living, and move toward ordinary happiness/unhappiness.

Stage 4. Move from incompleteness to capacity for joy and freedom.

Seven randomized controlled trials have shown that DBT can be useful in treating borderline personality disorder.^4-10 The initial trial by Linehan et al⁴ included 47 women ages 18 to 45 who met criteria for borderline personality disorder and had at least two parasuicide incidents in the previous 5 years, with one in the previous 8 weeks. Treatment lasted 1 year, and subjects agreed to stop other individual psychotherapy if assigned to DBT.

Subjects were then randomly assigned to either DBT or “treatment as usual” in the community. In the various DBT studies, treatment-as-usual has included community therapists, Department of Veterans Affairs outpatient treatment, client-centered therapy, and treatment by persons identified by their peers as experts in their communities.

Subjects were assessed every 4 months while in treatment and for 1 year thereafter. DBT was more effective than usual treatment in:

• reducing suicide attempts and self-injury
• decreasing premature dropout from therapy
• reducing emergency room admissions and length of psychiatric hospitalization
• reducing drug abuse, depression, hopelessness, and anger.

Table 3

Modes of therapy in outpatient dialectical behavioral therapy

RECOMMENDATIONS

Some psychiatrists may find “borderline patients” frustrating and unpleasant to treat. DBT therapists, however, make two assumptions that can help anyone working with individuals with borderline personality disorder. To avoid falling into the trap of polarization with these patients, assume that:

• they are doing the best they can
• their efforts are insufficient to meet their needs.

They therefore need to do better, and the therapist’s job is to help them do so. Also assume that if you try to help a patient with borderline personality disorder, you will need help, too. We require DBT therapists to participate in consultation teams.

Training. DBT is a comprehensive program that requires familiarity with the manuals mentioned in this article (see Related resources). Some teams have learned DBT through self-study and consultation with other teams.

If you plan to offer DBT to patients with borderline personality disorder, we recommend that you be:

• trained in behavior therapy and CBT
• familiar with research on emotions and processes involved in emotion regulation.

If you have not had CBT training, find a behavior therapist to join your team or get consultation from a behavior therapist.

An intensive training course in DBT—with 2 weeks of instruction and case consultation and several months of consultation with someone well-versed in DBT—is an efficient way to become familiar with the most critical principles of the treatment. If you cannot train toward adherent delivery of individual therapy, we recommend referring patients to someone trained in DBT.

Related resources

• Lieb K, Zanarini MC, Schmahl C, et al. Borderline personality disorder. Lancet 2004;364(9432):453-61.
• University of Washington, Behavioral Research and Therapy Clinics. www.brtc.psych.washington.edu/frameResearch.htm;
  www.brtc.psych.washington.edu/framePublications.htm
• Behavioral Tech, LLC. Consultation and training in dialectical behavioral therapy. www.behavioraltech.org.

Disclosures

Dr. DuBose is president and CEO/co-owner of DBT Center of Seattle, PLLC, and a speaker for Behavioral Tech, LLC.

Dr. Linehan is a shareholder in Behavioral Tech Research, Inc., which develops computerized training for DBT, a DBT trainer for Behavioral Tech, LLC, and the author of two books on DBT. She also receives research grants from the National Institute of Mental Health and National Institute on Drug Abuse.

Posttraumatic stress disorder (PTSD) is underdiagnosed among combat-exposed individuals and overdiagnosed among civilians. An expanded, nondichotomous checklist of emotional and physical signs following a disaster may help address this problem.

PTSD diagnostic criteria shortcomings

Schnurr et al calculated that DSM-IV-TR diagnostic criteria A1 and A2 for PTSD together have a 34% positive predictive value when applied to victims of violent crime.¹ Many who meet these criteria may not need intervention, and some interventions—such as critical incident stress debriefing—may be detrimental.^2,3

DSM-IV criteria A1 and A2 do not take into account common peritraumatic autonomic activation signs—shortness of breath, tremulousness, racing heart, and sweaty palms/cold sweat—that are part of the human hardwired acute response to threat.⁴ Last year we published a research checklist of criteria A1 and A2 symptoms plus the four autonomic signs, which we collectively refer to as “criterion A3.”⁴

A preliminary (tentatively weighted) clinical version of this checklist, the PTSD Criterion A3 Checklist (Table), may be useful for screening persons in the acute aftermath of a disaster. While more research is needed, this version is:

Table

PTSD Criterion A3 Checklist

Fear-specific. The checklist includes queries about two peritraumatic, fear-specific signs (tremulousness and sweaty palms/cold sweat) as well as peritraumatic tachycardia and dyspnea.

Brief. This tool takes as little as 2 minutes to administer, thus minimizing the burden on victims in the days or weeks after a mass disaster.

Non-dichotomous but easy to score. One point is scored for each “Yes” answer for 8 of the 10 queries; “Yes” answers to the two other queries are worth 4 and 3 points, respectively. A total score of 5 or more may indicate a need for preventive intervention such as propranolol, 40 mg tid or qid for 7 to 10 days.^5,6

Minimizes stigma. Assessing peritraumatic physical signs may help minimize stigma-related bias.⁴ This is important when screening persons likely to underreport criterion A2 symptoms, including:

• veterans
• military personnel
• firefighters
• police officers
• men in general
• persons from ethnic cultures in which having psychiatric symptoms is viewed as disgraceful.

Easy to remember. After a few administrations, the queries can be easily memorized and incorporated into initial assessments. The four acute autonomic activation signs can be remembered with the acronym “STRS” (shortness of breath, trembling, racing heart, sweaty palms). Consider “A3” a mnemonic for “acute autonomic activation.”

Posttraumatic stress disorder (PTSD) is underdiagnosed among combat-exposed individuals and overdiagnosed among civilians. An expanded, nondichotomous checklist of emotional and physical signs following a disaster may help address this problem.

PTSD diagnostic criteria shortcomings

Schnurr et al calculated that DSM-IV-TR diagnostic criteria A1 and A2 for PTSD together have a 34% positive predictive value when applied to victims of violent crime.¹ Many who meet these criteria may not need intervention, and some interventions—such as critical incident stress debriefing—may be detrimental.^2,3

DSM-IV criteria A1 and A2 do not take into account common peritraumatic autonomic activation signs—shortness of breath, tremulousness, racing heart, and sweaty palms/cold sweat—that are part of the human hardwired acute response to threat.⁴ Last year we published a research checklist of criteria A1 and A2 symptoms plus the four autonomic signs, which we collectively refer to as “criterion A3.”⁴

A preliminary (tentatively weighted) clinical version of this checklist, the PTSD Criterion A3 Checklist (Table), may be useful for screening persons in the acute aftermath of a disaster. While more research is needed, this version is:

Table

PTSD Criterion A3 Checklist

Fear-specific. The checklist includes queries about two peritraumatic, fear-specific signs (tremulousness and sweaty palms/cold sweat) as well as peritraumatic tachycardia and dyspnea.

Brief. This tool takes as little as 2 minutes to administer, thus minimizing the burden on victims in the days or weeks after a mass disaster.

Non-dichotomous but easy to score. One point is scored for each “Yes” answer for 8 of the 10 queries; “Yes” answers to the two other queries are worth 4 and 3 points, respectively. A total score of 5 or more may indicate a need for preventive intervention such as propranolol, 40 mg tid or qid for 7 to 10 days.^5,6

Minimizes stigma. Assessing peritraumatic physical signs may help minimize stigma-related bias.⁴ This is important when screening persons likely to underreport criterion A2 symptoms, including:

• veterans
• military personnel
• firefighters
• police officers
• men in general
• persons from ethnic cultures in which having psychiatric symptoms is viewed as disgraceful.

Easy to remember. After a few administrations, the queries can be easily memorized and incorporated into initial assessments. The four acute autonomic activation signs can be remembered with the acronym “STRS” (shortness of breath, trembling, racing heart, sweaty palms). Consider “A3” a mnemonic for “acute autonomic activation.”

Posttraumatic stress disorder (PTSD) is underdiagnosed among combat-exposed individuals and overdiagnosed among civilians. An expanded, nondichotomous checklist of emotional and physical signs following a disaster may help address this problem.

PTSD diagnostic criteria shortcomings

Schnurr et al calculated that DSM-IV-TR diagnostic criteria A1 and A2 for PTSD together have a 34% positive predictive value when applied to victims of violent crime.¹ Many who meet these criteria may not need intervention, and some interventions—such as critical incident stress debriefing—may be detrimental.^2,3

DSM-IV criteria A1 and A2 do not take into account common peritraumatic autonomic activation signs—shortness of breath, tremulousness, racing heart, and sweaty palms/cold sweat—that are part of the human hardwired acute response to threat.⁴ Last year we published a research checklist of criteria A1 and A2 symptoms plus the four autonomic signs, which we collectively refer to as “criterion A3.”⁴

A preliminary (tentatively weighted) clinical version of this checklist, the PTSD Criterion A3 Checklist (Table), may be useful for screening persons in the acute aftermath of a disaster. While more research is needed, this version is:

Table

PTSD Criterion A3 Checklist

Fear-specific. The checklist includes queries about two peritraumatic, fear-specific signs (tremulousness and sweaty palms/cold sweat) as well as peritraumatic tachycardia and dyspnea.

Brief. This tool takes as little as 2 minutes to administer, thus minimizing the burden on victims in the days or weeks after a mass disaster.

Non-dichotomous but easy to score. One point is scored for each “Yes” answer for 8 of the 10 queries; “Yes” answers to the two other queries are worth 4 and 3 points, respectively. A total score of 5 or more may indicate a need for preventive intervention such as propranolol, 40 mg tid or qid for 7 to 10 days.^5,6

Minimizes stigma. Assessing peritraumatic physical signs may help minimize stigma-related bias.⁴ This is important when screening persons likely to underreport criterion A2 symptoms, including:

• veterans
• military personnel
• firefighters
• police officers
• men in general
• persons from ethnic cultures in which having psychiatric symptoms is viewed as disgraceful.

Easy to remember. After a few administrations, the queries can be easily memorized and incorporated into initial assessments. The four acute autonomic activation signs can be remembered with the acronym “STRS” (shortness of breath, trembling, racing heart, sweaty palms). Consider “A3” a mnemonic for “acute autonomic activation.”

LONDON — Despite concerns that the polyvalent pneumococcal vaccine may be inadequately protective in patients with lupus, most patients with severe disease can benefit from receiving it, Catherine Naveau, M.D., said at the Sixth European Lupus Meeting.

Invasive infections by common pathogens and opportunistic agents are frequent in patients with systemic lupus erythematosus and remain one of the leading causes of death, said Dr. Naveau of the rheumatology department, University Clinics Saint-Luc, Catholic University of Louvain, Brussels.

A review of the files of 208 patients from the Louvain lupus cohort identified 5 (2.5%) who had a history of pneumococcal septicemia prior to 1999.

“Since 1999 we have been vaccinating all our severe lupus patients with a polyvalent pneumococcal polysaccharide vaccine, and 5 years later we have not observed a single case of pneumococcal septicemia in vaccinated patients,” the rheumatologist said.

The five infected patients were female and ranged in age from 13 to 54 years. All had septic shock and unequivocal evidence on blood cultures of systemic Streptococcus pneumoniae infections, she said.

Three of the patients had infections of the central nervous system—two meningitis and one meningoencephalitis—one had bilateral pneumonia, and one had septic arthritis of the hip.

At the time of their infectious episode four of the five were being treated with corticosteroids, though at low to moderate doses ranging from the equivalent of 5 mg to 20 mg of prednisolone per day, Dr. Naveau reported in a poster session at the meeting, which was sponsored by the British Society for Rheumatology.

Only one was receiving a cytotoxic agent—intravenous cyclophosphamide.

All required treatment in the intensive care unit and survived without major organ damage, except for permanent bilateral hearing loss in one patient. “This series emphasizes the unusual incidence and severity of pneumococcal sepsis in systemic lupus erythematosus and suggests that vaccination should be offered to severe lupus patients,” Dr. Naveau said.

The U.S. Advisory Committee on Immunization Practices, while not mentioning lupus specifically, recommends the pneumococcal vaccine for patients who are immunocompromised or are being treated with immunosuppressive therapies.

The Lupus Foundation of America has acknowledged that the antibody response to the vaccine is inadequate in patients with severe lupus and in those being treated with corticosteroids and alkylating agents, but recommends it as being highly effective in the majority of lupus patients.

There have been reports of disease flares after vaccination with the pneumococcal vaccine, but in one of the largest reported series, no changes in lupus disease activity were seen in 73 patients following immunization with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines (Arthritis Rheum. 1998;41:1828-34).

In addition, that study showed that the majority of patients developed protective levels of antibody to TT (90%) and HIB (88%). Protective antibody levels could not be determined for pneumococcus but almost half of the patients developed a fourfold antibody response. Antibody responses tended to be lower in patients with active disease who were being treated with immunosuppressive therapy.

LONDON — Despite concerns that the polyvalent pneumococcal vaccine may be inadequately protective in patients with lupus, most patients with severe disease can benefit from receiving it, Catherine Naveau, M.D., said at the Sixth European Lupus Meeting.

Invasive infections by common pathogens and opportunistic agents are frequent in patients with systemic lupus erythematosus and remain one of the leading causes of death, said Dr. Naveau of the rheumatology department, University Clinics Saint-Luc, Catholic University of Louvain, Brussels.

A review of the files of 208 patients from the Louvain lupus cohort identified 5 (2.5%) who had a history of pneumococcal septicemia prior to 1999.

“Since 1999 we have been vaccinating all our severe lupus patients with a polyvalent pneumococcal polysaccharide vaccine, and 5 years later we have not observed a single case of pneumococcal septicemia in vaccinated patients,” the rheumatologist said.

The five infected patients were female and ranged in age from 13 to 54 years. All had septic shock and unequivocal evidence on blood cultures of systemic Streptococcus pneumoniae infections, she said.

Three of the patients had infections of the central nervous system—two meningitis and one meningoencephalitis—one had bilateral pneumonia, and one had septic arthritis of the hip.

At the time of their infectious episode four of the five were being treated with corticosteroids, though at low to moderate doses ranging from the equivalent of 5 mg to 20 mg of prednisolone per day, Dr. Naveau reported in a poster session at the meeting, which was sponsored by the British Society for Rheumatology.

Only one was receiving a cytotoxic agent—intravenous cyclophosphamide.

All required treatment in the intensive care unit and survived without major organ damage, except for permanent bilateral hearing loss in one patient. “This series emphasizes the unusual incidence and severity of pneumococcal sepsis in systemic lupus erythematosus and suggests that vaccination should be offered to severe lupus patients,” Dr. Naveau said.

The U.S. Advisory Committee on Immunization Practices, while not mentioning lupus specifically, recommends the pneumococcal vaccine for patients who are immunocompromised or are being treated with immunosuppressive therapies.

The Lupus Foundation of America has acknowledged that the antibody response to the vaccine is inadequate in patients with severe lupus and in those being treated with corticosteroids and alkylating agents, but recommends it as being highly effective in the majority of lupus patients.

There have been reports of disease flares after vaccination with the pneumococcal vaccine, but in one of the largest reported series, no changes in lupus disease activity were seen in 73 patients following immunization with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines (Arthritis Rheum. 1998;41:1828-34).

In addition, that study showed that the majority of patients developed protective levels of antibody to TT (90%) and HIB (88%). Protective antibody levels could not be determined for pneumococcus but almost half of the patients developed a fourfold antibody response. Antibody responses tended to be lower in patients with active disease who were being treated with immunosuppressive therapy.

LONDON — Despite concerns that the polyvalent pneumococcal vaccine may be inadequately protective in patients with lupus, most patients with severe disease can benefit from receiving it, Catherine Naveau, M.D., said at the Sixth European Lupus Meeting.

Invasive infections by common pathogens and opportunistic agents are frequent in patients with systemic lupus erythematosus and remain one of the leading causes of death, said Dr. Naveau of the rheumatology department, University Clinics Saint-Luc, Catholic University of Louvain, Brussels.

A review of the files of 208 patients from the Louvain lupus cohort identified 5 (2.5%) who had a history of pneumococcal septicemia prior to 1999.

“Since 1999 we have been vaccinating all our severe lupus patients with a polyvalent pneumococcal polysaccharide vaccine, and 5 years later we have not observed a single case of pneumococcal septicemia in vaccinated patients,” the rheumatologist said.

The five infected patients were female and ranged in age from 13 to 54 years. All had septic shock and unequivocal evidence on blood cultures of systemic Streptococcus pneumoniae infections, she said.

Three of the patients had infections of the central nervous system—two meningitis and one meningoencephalitis—one had bilateral pneumonia, and one had septic arthritis of the hip.

At the time of their infectious episode four of the five were being treated with corticosteroids, though at low to moderate doses ranging from the equivalent of 5 mg to 20 mg of prednisolone per day, Dr. Naveau reported in a poster session at the meeting, which was sponsored by the British Society for Rheumatology.

Only one was receiving a cytotoxic agent—intravenous cyclophosphamide.

All required treatment in the intensive care unit and survived without major organ damage, except for permanent bilateral hearing loss in one patient. “This series emphasizes the unusual incidence and severity of pneumococcal sepsis in systemic lupus erythematosus and suggests that vaccination should be offered to severe lupus patients,” Dr. Naveau said.

The U.S. Advisory Committee on Immunization Practices, while not mentioning lupus specifically, recommends the pneumococcal vaccine for patients who are immunocompromised or are being treated with immunosuppressive therapies.

The Lupus Foundation of America has acknowledged that the antibody response to the vaccine is inadequate in patients with severe lupus and in those being treated with corticosteroids and alkylating agents, but recommends it as being highly effective in the majority of lupus patients.

There have been reports of disease flares after vaccination with the pneumococcal vaccine, but in one of the largest reported series, no changes in lupus disease activity were seen in 73 patients following immunization with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines (Arthritis Rheum. 1998;41:1828-34).

In addition, that study showed that the majority of patients developed protective levels of antibody to TT (90%) and HIB (88%). Protective antibody levels could not be determined for pneumococcus but almost half of the patients developed a fourfold antibody response. Antibody responses tended to be lower in patients with active disease who were being treated with immunosuppressive therapy.

SNOWMASS, COLO. — Admonitions persist against patients with polymyositis and dermatomyositis engaging in exercise, despite research showing it can be beneficial, Ingrid E. Lundberg, M.D., said at a symposium sponsored by the American College of Rheumatology.

Creatine supplements may also help improve function.

The notion that exercise could aggravate myositis stems in part from observations of muscle inflammation among marathon runners, Dr. Lundberg explained.

No study has ever shown harm with exercise in polymyositis or dermatomyositis patients, and yet medical textbook articles continued to suggest that such patients should avoid exercise, said Dr. Lundberg of the rheumatology unit at Karolinska University Hospital, Stockholm.

Now, a group of researchers including Dr. Lundberg and her colleagues are conducting small studies whose findings challenge the idea that exercise increases inflammation. In fact, many have found that exercise actually improves function.

In one observational study involving 10 patients with stable chronic polymyositis or dermatomyositis following an exercise program, none of the participants developed signs of aggravated disease activity as measured by MRI, plasma creatine phosphokinase level, and biopsy. Instead, all participants had improvements in their muscle function, according to an index test; among six of the patients the improvement was significant, Dr. Lundberg said at the symposium.

The 12-week program involved 15 minutes of resistance strength training and 15 minutes of walking 5 days a week.

In addition, the patients experienced reductions in their “bodily pain,” according to measures on the Short Form 36 health survey questionnaire (Rheumatology 1999;38:608-11).

Another study conducted around the same time assessed the effects of aerobic training rather than strength training. In that investigation, eight patients were assigned to a program that included stationary cycling and step aerobics. They were compared with five control patients given no intervention. At the end of 6 months, the patients who trained had a mean 28% increase in aerobic capacity and a 34% increase in muscle torque strength. They also had a mean 8% decrease in their resting heart rate (Br. J. Rheumatol. 1998;37:1338-42). There was no change in the controls.

Findings from another study, conducted by Dr. Lundberg and her colleagues, suggest that exercise may even be beneficial in early active disease.

In a study presented at the American College of Rheumatology last year, they found that creatine paired with exercise significantly improved muscle function over exercise alone. For that study, 18 patients were assigned to a combination program of creatine and exercise, and 19 patients to exercise alone. The patients assigned to creatine took a loading dose of 30 g/kg a day for 8 days and then a daily dose of 3 g/kg for 6 months.

At follow-up, the patients who took creatine had an average 13% improvement on a test of physical activity that included a 5-minute walking test and climbing stairs. That compared with an average 3% improvement for those in the control group.

Corticosteroid treatment remains the standard initial therapy for polymyositis and dermatomyositis, but physicians should keep in mind that it's not an evidence-based approach, she said. Controlled clinical trials of corticosteroids in these patients have never been conducted, so there are no data on optimal starting dosages, or on how long one should treat before attempting to taper, she said.

Most experts recommend starting prednisone at 40-60 mg daily for about 1 month, and then slowly tapering the corticosteroid while monitoring plasma creatine phosphokinase levels.

Dr. Lundberg, however, said she recommends following muscle function before tapering because muscle function returns more slowly than do normal levels of creatine phosphokinase, and the return of muscle strength may take more than a month.

Studies have shown that 75% of patients respond to corticosteroid therapy, but few recover muscle function fully, and there is a high rate of adverse effects.

Azathioprine, 2 mg/kg a day, can be added to the prednisone to decrease corticosteroid exposure; methotrexate, 7.5-25 mg/wk, also can be effective for patients who do not respond to prednisone.

Any patient who doesn't respond to corticosteroid treatment should have their diagnosis reevaluated before continuing treatment, with either a repeat MRI or a new muscle biopsy, she advised.

Cyclosporine has been shown to be as effective as methotrexate and may even be preferable for those patients with concurrent interstitial lung disease.

Experimental treatments for myositis include tacrolimus, which showed “impressive” results in a small, open-label trial of eight patients who were not responsive to corticosteroids and anti-tumor necrosis factor therapy. However, outcomes involving 13 similar patients at Dr. Lundberg's institution were not as favorable. Of those patients, three had some improvement, but not in muscle function, two worsened, and the rest did not respond. Moreover, muscle inflammation did not appear to be impacted.

SNOWMASS, COLO. — Admonitions persist against patients with polymyositis and dermatomyositis engaging in exercise, despite research showing it can be beneficial, Ingrid E. Lundberg, M.D., said at a symposium sponsored by the American College of Rheumatology.

Creatine supplements may also help improve function.

The notion that exercise could aggravate myositis stems in part from observations of muscle inflammation among marathon runners, Dr. Lundberg explained.

No study has ever shown harm with exercise in polymyositis or dermatomyositis patients, and yet medical textbook articles continued to suggest that such patients should avoid exercise, said Dr. Lundberg of the rheumatology unit at Karolinska University Hospital, Stockholm.

Now, a group of researchers including Dr. Lundberg and her colleagues are conducting small studies whose findings challenge the idea that exercise increases inflammation. In fact, many have found that exercise actually improves function.

In one observational study involving 10 patients with stable chronic polymyositis or dermatomyositis following an exercise program, none of the participants developed signs of aggravated disease activity as measured by MRI, plasma creatine phosphokinase level, and biopsy. Instead, all participants had improvements in their muscle function, according to an index test; among six of the patients the improvement was significant, Dr. Lundberg said at the symposium.

The 12-week program involved 15 minutes of resistance strength training and 15 minutes of walking 5 days a week.

In addition, the patients experienced reductions in their “bodily pain,” according to measures on the Short Form 36 health survey questionnaire (Rheumatology 1999;38:608-11).

Another study conducted around the same time assessed the effects of aerobic training rather than strength training. In that investigation, eight patients were assigned to a program that included stationary cycling and step aerobics. They were compared with five control patients given no intervention. At the end of 6 months, the patients who trained had a mean 28% increase in aerobic capacity and a 34% increase in muscle torque strength. They also had a mean 8% decrease in their resting heart rate (Br. J. Rheumatol. 1998;37:1338-42). There was no change in the controls.

Findings from another study, conducted by Dr. Lundberg and her colleagues, suggest that exercise may even be beneficial in early active disease.

In a study presented at the American College of Rheumatology last year, they found that creatine paired with exercise significantly improved muscle function over exercise alone. For that study, 18 patients were assigned to a combination program of creatine and exercise, and 19 patients to exercise alone. The patients assigned to creatine took a loading dose of 30 g/kg a day for 8 days and then a daily dose of 3 g/kg for 6 months.

At follow-up, the patients who took creatine had an average 13% improvement on a test of physical activity that included a 5-minute walking test and climbing stairs. That compared with an average 3% improvement for those in the control group.

Corticosteroid treatment remains the standard initial therapy for polymyositis and dermatomyositis, but physicians should keep in mind that it's not an evidence-based approach, she said. Controlled clinical trials of corticosteroids in these patients have never been conducted, so there are no data on optimal starting dosages, or on how long one should treat before attempting to taper, she said.

Most experts recommend starting prednisone at 40-60 mg daily for about 1 month, and then slowly tapering the corticosteroid while monitoring plasma creatine phosphokinase levels.

Dr. Lundberg, however, said she recommends following muscle function before tapering because muscle function returns more slowly than do normal levels of creatine phosphokinase, and the return of muscle strength may take more than a month.

Studies have shown that 75% of patients respond to corticosteroid therapy, but few recover muscle function fully, and there is a high rate of adverse effects.

Azathioprine, 2 mg/kg a day, can be added to the prednisone to decrease corticosteroid exposure; methotrexate, 7.5-25 mg/wk, also can be effective for patients who do not respond to prednisone.

Any patient who doesn't respond to corticosteroid treatment should have their diagnosis reevaluated before continuing treatment, with either a repeat MRI or a new muscle biopsy, she advised.

Cyclosporine has been shown to be as effective as methotrexate and may even be preferable for those patients with concurrent interstitial lung disease.

Experimental treatments for myositis include tacrolimus, which showed “impressive” results in a small, open-label trial of eight patients who were not responsive to corticosteroids and anti-tumor necrosis factor therapy. However, outcomes involving 13 similar patients at Dr. Lundberg's institution were not as favorable. Of those patients, three had some improvement, but not in muscle function, two worsened, and the rest did not respond. Moreover, muscle inflammation did not appear to be impacted.

SNOWMASS, COLO. — Admonitions persist against patients with polymyositis and dermatomyositis engaging in exercise, despite research showing it can be beneficial, Ingrid E. Lundberg, M.D., said at a symposium sponsored by the American College of Rheumatology.

Creatine supplements may also help improve function.

The notion that exercise could aggravate myositis stems in part from observations of muscle inflammation among marathon runners, Dr. Lundberg explained.

No study has ever shown harm with exercise in polymyositis or dermatomyositis patients, and yet medical textbook articles continued to suggest that such patients should avoid exercise, said Dr. Lundberg of the rheumatology unit at Karolinska University Hospital, Stockholm.

Now, a group of researchers including Dr. Lundberg and her colleagues are conducting small studies whose findings challenge the idea that exercise increases inflammation. In fact, many have found that exercise actually improves function.

In one observational study involving 10 patients with stable chronic polymyositis or dermatomyositis following an exercise program, none of the participants developed signs of aggravated disease activity as measured by MRI, plasma creatine phosphokinase level, and biopsy. Instead, all participants had improvements in their muscle function, according to an index test; among six of the patients the improvement was significant, Dr. Lundberg said at the symposium.

The 12-week program involved 15 minutes of resistance strength training and 15 minutes of walking 5 days a week.

In addition, the patients experienced reductions in their “bodily pain,” according to measures on the Short Form 36 health survey questionnaire (Rheumatology 1999;38:608-11).

Another study conducted around the same time assessed the effects of aerobic training rather than strength training. In that investigation, eight patients were assigned to a program that included stationary cycling and step aerobics. They were compared with five control patients given no intervention. At the end of 6 months, the patients who trained had a mean 28% increase in aerobic capacity and a 34% increase in muscle torque strength. They also had a mean 8% decrease in their resting heart rate (Br. J. Rheumatol. 1998;37:1338-42). There was no change in the controls.

Findings from another study, conducted by Dr. Lundberg and her colleagues, suggest that exercise may even be beneficial in early active disease.

In a study presented at the American College of Rheumatology last year, they found that creatine paired with exercise significantly improved muscle function over exercise alone. For that study, 18 patients were assigned to a combination program of creatine and exercise, and 19 patients to exercise alone. The patients assigned to creatine took a loading dose of 30 g/kg a day for 8 days and then a daily dose of 3 g/kg for 6 months.

At follow-up, the patients who took creatine had an average 13% improvement on a test of physical activity that included a 5-minute walking test and climbing stairs. That compared with an average 3% improvement for those in the control group.

Corticosteroid treatment remains the standard initial therapy for polymyositis and dermatomyositis, but physicians should keep in mind that it's not an evidence-based approach, she said. Controlled clinical trials of corticosteroids in these patients have never been conducted, so there are no data on optimal starting dosages, or on how long one should treat before attempting to taper, she said.

Most experts recommend starting prednisone at 40-60 mg daily for about 1 month, and then slowly tapering the corticosteroid while monitoring plasma creatine phosphokinase levels.

Dr. Lundberg, however, said she recommends following muscle function before tapering because muscle function returns more slowly than do normal levels of creatine phosphokinase, and the return of muscle strength may take more than a month.

Studies have shown that 75% of patients respond to corticosteroid therapy, but few recover muscle function fully, and there is a high rate of adverse effects.

Azathioprine, 2 mg/kg a day, can be added to the prednisone to decrease corticosteroid exposure; methotrexate, 7.5-25 mg/wk, also can be effective for patients who do not respond to prednisone.

Any patient who doesn't respond to corticosteroid treatment should have their diagnosis reevaluated before continuing treatment, with either a repeat MRI or a new muscle biopsy, she advised.

Cyclosporine has been shown to be as effective as methotrexate and may even be preferable for those patients with concurrent interstitial lung disease.

Experimental treatments for myositis include tacrolimus, which showed “impressive” results in a small, open-label trial of eight patients who were not responsive to corticosteroids and anti-tumor necrosis factor therapy. However, outcomes involving 13 similar patients at Dr. Lundberg's institution were not as favorable. Of those patients, three had some improvement, but not in muscle function, two worsened, and the rest did not respond. Moreover, muscle inflammation did not appear to be impacted.

LONDON — Patients with systemic lupus erythematosus should be evaluated on an annual basis for cardiovascular risk until such time as specific recommendations are formulated, Heiko Schotte, M.D., said at the Sixth European Lupus Meeting.

Results of procedures that detect coronary insufficiency, surrogates of atherosclerotic burden, and echocardiographic findings are often abnormal in SLE, but evidence to support routine screening is not currently available. “Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest annual assessment of traditional risk factors including diabetes mellitus, dyslipidemia, hypertension, smoking, and family history of premature coronary disease,” Dr. Schotte said in a poster session at the meeting, which was sponsored by the British Society for Rheumatology.

If two or more risk factors are present, an exercise ECG should be done, he said.

The cardiac manifestations of SLE can involve almost all components of the heart—pericardium, myocardium, and valves—and pulmonary hypertension also often develops during the course of disease. Echocardiography also should be done each year to look for any of these abnormalities, even for patients who are asymptomatic, he said.

These recommendations must be confirmed in prospective studies, and should be enlarged to include other SLE-specific risk factors such as antiphospholipid antibodies and long-term corticosteroid therapy, said Dr. Schotte of the department of medicine, Muenster (Germany) University Hospital.

LONDON — Patients with systemic lupus erythematosus should be evaluated on an annual basis for cardiovascular risk until such time as specific recommendations are formulated, Heiko Schotte, M.D., said at the Sixth European Lupus Meeting.

Results of procedures that detect coronary insufficiency, surrogates of atherosclerotic burden, and echocardiographic findings are often abnormal in SLE, but evidence to support routine screening is not currently available. “Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest annual assessment of traditional risk factors including diabetes mellitus, dyslipidemia, hypertension, smoking, and family history of premature coronary disease,” Dr. Schotte said in a poster session at the meeting, which was sponsored by the British Society for Rheumatology.

If two or more risk factors are present, an exercise ECG should be done, he said.

The cardiac manifestations of SLE can involve almost all components of the heart—pericardium, myocardium, and valves—and pulmonary hypertension also often develops during the course of disease. Echocardiography also should be done each year to look for any of these abnormalities, even for patients who are asymptomatic, he said.

These recommendations must be confirmed in prospective studies, and should be enlarged to include other SLE-specific risk factors such as antiphospholipid antibodies and long-term corticosteroid therapy, said Dr. Schotte of the department of medicine, Muenster (Germany) University Hospital.

LONDON — Patients with systemic lupus erythematosus should be evaluated on an annual basis for cardiovascular risk until such time as specific recommendations are formulated, Heiko Schotte, M.D., said at the Sixth European Lupus Meeting.

Results of procedures that detect coronary insufficiency, surrogates of atherosclerotic burden, and echocardiographic findings are often abnormal in SLE, but evidence to support routine screening is not currently available. “Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest annual assessment of traditional risk factors including diabetes mellitus, dyslipidemia, hypertension, smoking, and family history of premature coronary disease,” Dr. Schotte said in a poster session at the meeting, which was sponsored by the British Society for Rheumatology.

If two or more risk factors are present, an exercise ECG should be done, he said.

The cardiac manifestations of SLE can involve almost all components of the heart—pericardium, myocardium, and valves—and pulmonary hypertension also often develops during the course of disease. Echocardiography also should be done each year to look for any of these abnormalities, even for patients who are asymptomatic, he said.

These recommendations must be confirmed in prospective studies, and should be enlarged to include other SLE-specific risk factors such as antiphospholipid antibodies and long-term corticosteroid therapy, said Dr. Schotte of the department of medicine, Muenster (Germany) University Hospital.

NEW ORLEANS — Patients with refractory systemic lupus erythematosus have had “substantial improvements” following autologous stem cell transplants in an uncontrolled, phase I-II study.

The next step is to test the treatment in a randomized, controlled trial, Richard Burt, M.D., said at the southern regional meeting of the American Federation for Medical Research.

As of February, Dr. Burt had followed 48 patients treated with nonmyeloablative stem cell transplants and found that they stayed in remission for as long as 88 months and for an average of 33 months.

Among patients followed for at least 2 years, 70% were in remission; after at least 5 years, 50% were in remission, said Dr. Burt, chief of the division of immunotherapy and autoimmune diseases at Northwestern University in Chicago. He defined remission as requiring less than 10 mg/day of prednisone. Before receiving stem cell transplants, these patients required 50-100 mg of prednisone daily.

The treatment aims to ablate a patient's dysfunctional immune system and then regenerate immunity with autologous stem cells. In patients with systemic lupus erythematosus (SLE), as well as other autoimmune diseases, the pathologic defect is presumed to be environmental and not genetic, and hence the patient's stem cells should be able to regenerate a more normally functioning immune system.

A key to the success of this program is that patients receive a conditioning regimen that is immunoablative but not myeloablative. This makes the treatment safer, Dr. Burt said.

The series enrolled patients who had steroid-dependent SLE, with an average age of 26 years; 87% were women.

Stem cells were mobilized by using a combination of low-dose cyclophosphamide and granulocyte colony-stimulating factor. Stem cells were harvested 10 days later. Patients were then immunoablated with a combination regimen of high-dose cyclophosphamide, a total of 200 mg/kg, along with equine antithymocyte globulin to eliminate T cells. After the ablative regimen was complete, patients received an infusion of their autologous stem cells.

During recovery, patients required an average of six red blood cell transfusions and seven platelet transfusions. Adequate neurophil recovery usually occurred within 9 days after completion of the immunoablative treatment, and platelets usually recovered by day 12.

Patients generally were discharged from the hospital 14 days after immunoablation.

Following treatment, patients had a marked reduction in their level of antinuclear antibody and an increase in complement, so that levels returned to the normal range. Proteinuria severity also improved markedly, with reductions of about 75%. Many patients have also had resolution of pneumonitis or alveolar hemorrhage.

Antiphospholipid antibody levels dropped, enabling about 80% of patients to stop chronic treatment with anticoagulants without the occurrence of thrombotic events during a mean of 17 months.

Since the start of this study 7 years ago, four patients have died from disease relapse, one has died following a traumatic accident, and one has died from an unrelated, late infection.

Dr. Burt believes this treatment is probably applicable to several different autoimmune diseases. He and his associates have already used it safely and with encouraging results in patients with other autoimmune disorders, including Crohn's disease and multiple sclerosis.

NEW ORLEANS — Patients with refractory systemic lupus erythematosus have had “substantial improvements” following autologous stem cell transplants in an uncontrolled, phase I-II study.

The next step is to test the treatment in a randomized, controlled trial, Richard Burt, M.D., said at the southern regional meeting of the American Federation for Medical Research.

As of February, Dr. Burt had followed 48 patients treated with nonmyeloablative stem cell transplants and found that they stayed in remission for as long as 88 months and for an average of 33 months.

Among patients followed for at least 2 years, 70% were in remission; after at least 5 years, 50% were in remission, said Dr. Burt, chief of the division of immunotherapy and autoimmune diseases at Northwestern University in Chicago. He defined remission as requiring less than 10 mg/day of prednisone. Before receiving stem cell transplants, these patients required 50-100 mg of prednisone daily.

The treatment aims to ablate a patient's dysfunctional immune system and then regenerate immunity with autologous stem cells. In patients with systemic lupus erythematosus (SLE), as well as other autoimmune diseases, the pathologic defect is presumed to be environmental and not genetic, and hence the patient's stem cells should be able to regenerate a more normally functioning immune system.

A key to the success of this program is that patients receive a conditioning regimen that is immunoablative but not myeloablative. This makes the treatment safer, Dr. Burt said.

The series enrolled patients who had steroid-dependent SLE, with an average age of 26 years; 87% were women.

Stem cells were mobilized by using a combination of low-dose cyclophosphamide and granulocyte colony-stimulating factor. Stem cells were harvested 10 days later. Patients were then immunoablated with a combination regimen of high-dose cyclophosphamide, a total of 200 mg/kg, along with equine antithymocyte globulin to eliminate T cells. After the ablative regimen was complete, patients received an infusion of their autologous stem cells.

During recovery, patients required an average of six red blood cell transfusions and seven platelet transfusions. Adequate neurophil recovery usually occurred within 9 days after completion of the immunoablative treatment, and platelets usually recovered by day 12.

Patients generally were discharged from the hospital 14 days after immunoablation.

Following treatment, patients had a marked reduction in their level of antinuclear antibody and an increase in complement, so that levels returned to the normal range. Proteinuria severity also improved markedly, with reductions of about 75%. Many patients have also had resolution of pneumonitis or alveolar hemorrhage.

Antiphospholipid antibody levels dropped, enabling about 80% of patients to stop chronic treatment with anticoagulants without the occurrence of thrombotic events during a mean of 17 months.

Since the start of this study 7 years ago, four patients have died from disease relapse, one has died following a traumatic accident, and one has died from an unrelated, late infection.

Dr. Burt believes this treatment is probably applicable to several different autoimmune diseases. He and his associates have already used it safely and with encouraging results in patients with other autoimmune disorders, including Crohn's disease and multiple sclerosis.

NEW ORLEANS — Patients with refractory systemic lupus erythematosus have had “substantial improvements” following autologous stem cell transplants in an uncontrolled, phase I-II study.

The next step is to test the treatment in a randomized, controlled trial, Richard Burt, M.D., said at the southern regional meeting of the American Federation for Medical Research.

As of February, Dr. Burt had followed 48 patients treated with nonmyeloablative stem cell transplants and found that they stayed in remission for as long as 88 months and for an average of 33 months.

Among patients followed for at least 2 years, 70% were in remission; after at least 5 years, 50% were in remission, said Dr. Burt, chief of the division of immunotherapy and autoimmune diseases at Northwestern University in Chicago. He defined remission as requiring less than 10 mg/day of prednisone. Before receiving stem cell transplants, these patients required 50-100 mg of prednisone daily.

The treatment aims to ablate a patient's dysfunctional immune system and then regenerate immunity with autologous stem cells. In patients with systemic lupus erythematosus (SLE), as well as other autoimmune diseases, the pathologic defect is presumed to be environmental and not genetic, and hence the patient's stem cells should be able to regenerate a more normally functioning immune system.

A key to the success of this program is that patients receive a conditioning regimen that is immunoablative but not myeloablative. This makes the treatment safer, Dr. Burt said.

The series enrolled patients who had steroid-dependent SLE, with an average age of 26 years; 87% were women.

Stem cells were mobilized by using a combination of low-dose cyclophosphamide and granulocyte colony-stimulating factor. Stem cells were harvested 10 days later. Patients were then immunoablated with a combination regimen of high-dose cyclophosphamide, a total of 200 mg/kg, along with equine antithymocyte globulin to eliminate T cells. After the ablative regimen was complete, patients received an infusion of their autologous stem cells.

During recovery, patients required an average of six red blood cell transfusions and seven platelet transfusions. Adequate neurophil recovery usually occurred within 9 days after completion of the immunoablative treatment, and platelets usually recovered by day 12.

Patients generally were discharged from the hospital 14 days after immunoablation.

Following treatment, patients had a marked reduction in their level of antinuclear antibody and an increase in complement, so that levels returned to the normal range. Proteinuria severity also improved markedly, with reductions of about 75%. Many patients have also had resolution of pneumonitis or alveolar hemorrhage.

Antiphospholipid antibody levels dropped, enabling about 80% of patients to stop chronic treatment with anticoagulants without the occurrence of thrombotic events during a mean of 17 months.

Since the start of this study 7 years ago, four patients have died from disease relapse, one has died following a traumatic accident, and one has died from an unrelated, late infection.

Dr. Burt believes this treatment is probably applicable to several different autoimmune diseases. He and his associates have already used it safely and with encouraging results in patients with other autoimmune disorders, including Crohn's disease and multiple sclerosis.

LONDON — Women with lupus face an elevated risk of having cervical dysplasia, but the underlying cause of such pathology is still unclear, Michelle T. McHenry, M.B., said at the Sixth European Lupus Meeting.

Unlike the situation for healthy women, there appeared to be no association between cervical dysplasia and other traditional risk factors, such as a history of sexually transmitted disease, in a cohort of 221 women with systemic lupus erythematosus (SLE) identified through hospital records and the Northern Ireland pathology database.

Among this entire cohort, 74 (33%) had a lifetime history of having had at least one abnormal cervical smear, Dr. McHenry reported.

Of those, 45% had had more than one abnormal smear and 26% had had a high-grade abnormality, she said.

From the entire cohort, 141 patients agreed to participate in a study that involved answering a risk factor questionnaire and providing a current cervical smear. Adequate smears were obtained from 133 patients.

Low-grade abnormalities were found on 22 (17%) of these smears, which is twice the expected incidence, according to the Northern Ireland department of health statistics. High-grade abnormalities were identified on six (5%), which is three times the expected incidence, said Dr. McHenry, a rheumatologist at Queen's University Musculoskeletal Education and Research Unit, Belfast.

The abnormality was detected after the time of diagnosis of lupus in 63% of patients.

“Patients with SLE are at increased risk of cervical cancer but the reasons why are unclear, whether it is related to having the disease itself, to having active disease, [or] to the treatments we administer, or if traditional cervical cancer risk factors have a part to play,” Dr. McHenry said.

“When we assessed these patients for traditional cervical cancer risk factors, we found they were more likely to have had more sexual partners and more children,” she said at the meeting, which was sponsored by the British Society for Rheumatology.

There also was an increased risk of having a cervical smear abnormality among patients who had more active disease as reflected by the Systemic Lupus Activity Measure (SLAM) score, she said.

Other risk factors, including age at first sexual contact and history of ever having used oral contraceptives, were not associated with increased risk of cervical dysplasia. “And surprisingly, there was no association between abnormal cervical smear history and tobacco smoking,” she said. (See chart.)

Although a correlation was seen between high disease activity scores and history of cervical smear abnormality, there was no correlation with lupus damage scores or duration of disease.

Exposure to corticosteroids and immunosuppressive agents also did not differ between patients with and without abnormal cervical smear histories.

Further analyses will consider cumulative immunosuppressive doses and will compare human papillomavirus DNA findings between lupus patients and controls.

LONDON — Women with lupus face an elevated risk of having cervical dysplasia, but the underlying cause of such pathology is still unclear, Michelle T. McHenry, M.B., said at the Sixth European Lupus Meeting.

Unlike the situation for healthy women, there appeared to be no association between cervical dysplasia and other traditional risk factors, such as a history of sexually transmitted disease, in a cohort of 221 women with systemic lupus erythematosus (SLE) identified through hospital records and the Northern Ireland pathology database.

Among this entire cohort, 74 (33%) had a lifetime history of having had at least one abnormal cervical smear, Dr. McHenry reported.

Of those, 45% had had more than one abnormal smear and 26% had had a high-grade abnormality, she said.

From the entire cohort, 141 patients agreed to participate in a study that involved answering a risk factor questionnaire and providing a current cervical smear. Adequate smears were obtained from 133 patients.

Low-grade abnormalities were found on 22 (17%) of these smears, which is twice the expected incidence, according to the Northern Ireland department of health statistics. High-grade abnormalities were identified on six (5%), which is three times the expected incidence, said Dr. McHenry, a rheumatologist at Queen's University Musculoskeletal Education and Research Unit, Belfast.

The abnormality was detected after the time of diagnosis of lupus in 63% of patients.

“Patients with SLE are at increased risk of cervical cancer but the reasons why are unclear, whether it is related to having the disease itself, to having active disease, [or] to the treatments we administer, or if traditional cervical cancer risk factors have a part to play,” Dr. McHenry said.

“When we assessed these patients for traditional cervical cancer risk factors, we found they were more likely to have had more sexual partners and more children,” she said at the meeting, which was sponsored by the British Society for Rheumatology.

There also was an increased risk of having a cervical smear abnormality among patients who had more active disease as reflected by the Systemic Lupus Activity Measure (SLAM) score, she said.

Other risk factors, including age at first sexual contact and history of ever having used oral contraceptives, were not associated with increased risk of cervical dysplasia. “And surprisingly, there was no association between abnormal cervical smear history and tobacco smoking,” she said. (See chart.)

Although a correlation was seen between high disease activity scores and history of cervical smear abnormality, there was no correlation with lupus damage scores or duration of disease.

Exposure to corticosteroids and immunosuppressive agents also did not differ between patients with and without abnormal cervical smear histories.

Further analyses will consider cumulative immunosuppressive doses and will compare human papillomavirus DNA findings between lupus patients and controls.

LONDON — Women with lupus face an elevated risk of having cervical dysplasia, but the underlying cause of such pathology is still unclear, Michelle T. McHenry, M.B., said at the Sixth European Lupus Meeting.

Unlike the situation for healthy women, there appeared to be no association between cervical dysplasia and other traditional risk factors, such as a history of sexually transmitted disease, in a cohort of 221 women with systemic lupus erythematosus (SLE) identified through hospital records and the Northern Ireland pathology database.

Among this entire cohort, 74 (33%) had a lifetime history of having had at least one abnormal cervical smear, Dr. McHenry reported.

Of those, 45% had had more than one abnormal smear and 26% had had a high-grade abnormality, she said.

From the entire cohort, 141 patients agreed to participate in a study that involved answering a risk factor questionnaire and providing a current cervical smear. Adequate smears were obtained from 133 patients.

Low-grade abnormalities were found on 22 (17%) of these smears, which is twice the expected incidence, according to the Northern Ireland department of health statistics. High-grade abnormalities were identified on six (5%), which is three times the expected incidence, said Dr. McHenry, a rheumatologist at Queen's University Musculoskeletal Education and Research Unit, Belfast.

The abnormality was detected after the time of diagnosis of lupus in 63% of patients.

“Patients with SLE are at increased risk of cervical cancer but the reasons why are unclear, whether it is related to having the disease itself, to having active disease, [or] to the treatments we administer, or if traditional cervical cancer risk factors have a part to play,” Dr. McHenry said.

“When we assessed these patients for traditional cervical cancer risk factors, we found they were more likely to have had more sexual partners and more children,” she said at the meeting, which was sponsored by the British Society for Rheumatology.

There also was an increased risk of having a cervical smear abnormality among patients who had more active disease as reflected by the Systemic Lupus Activity Measure (SLAM) score, she said.

Other risk factors, including age at first sexual contact and history of ever having used oral contraceptives, were not associated with increased risk of cervical dysplasia. “And surprisingly, there was no association between abnormal cervical smear history and tobacco smoking,” she said. (See chart.)

Although a correlation was seen between high disease activity scores and history of cervical smear abnormality, there was no correlation with lupus damage scores or duration of disease.

Exposure to corticosteroids and immunosuppressive agents also did not differ between patients with and without abnormal cervical smear histories.

Further analyses will consider cumulative immunosuppressive doses and will compare human papillomavirus DNA findings between lupus patients and controls.