Treatment of borderline personality disorder (BPD) often is viewed as challenging and the results so discouraging that some clinicians avoid referrals of BPD patients.1-3 Psychotherapy has been the treatment mainstay for decades, and supportive approaches are probably the most widely employed.4 Psychodynamic therapy often has been recommended.
This article introduces a new evidence-based group treatment program that we developed for BPD patients. Systems Training for Emotional Predictability and Problem Solving (STEPPS) is founded on the successes of better known psychoeducational models but is easier for practicing psychiatrists to implement.
A different approach to BPD
Linehan5 introduced dialectical behavior therapy (DBT)—a manualized, time-limited, cognitive-behavioral approach in which patients learn to regulate their emotions and behaviors rather than change their personality structure. Other evidence-based BPD treatments include transference-focused psychotherapy,6 schema-focused psychotherapy,7 and Bateman and Fonagy’s mentalization program.8 For a description of the unique challenges presented by BPD patients, see Box.
In the mid-1990s, we set out to create a treatment program for our BPD patients in response to managed care directives to lower the cost of care, decrease length of inpatient treatment, and reduce rehospitalization rates. Despite DBT’s many appealing features, we felt this model was too lengthy and labor-intensive for our treatment setting. We concluded that modifying a program developed by Bartels and Crotty9 would serve our needs. This 12-week psychoeducational program:
- employs established cognitive-behavioral techniques in group treatment intended to supplement but not replace patients’ ongoing treatment
- incorporates a “systems” component that recognizes the importance of the patient’s family and friends.
We eventually renamed the program Systems Training for Emotional Predictability and Problem Solving (STEPPS)10 and created a new manual (see Related Resources) to simplify group leader training and ensure fidelity to the model. Data from 5 studies, including 2 randomized controlled trials (Table 1), show that STEPPS has a robust antidepressant effect and leads to broad-based improvements in the affective, cognitive, impulsive, and disturbed relationship domains of BPD.11-15
Why treating borderline personality disorder is so challenging
Borderline personality disorder (BPD) is 1 of the most challenging mental health conditions. BPD is surprisingly common, with prevalence rates of 0.5% to 1% in the community, 10% in outpatient mental health settings, and up to 20% in inpatient psychiatric settings.a-c Patients with BPD experience substantial functional impairment in several areas (eg, difficulty maintaining employment, disturbed interpersonal relationships, and disrupted family relationships).a,d,e
Many borderline patients have childhood histories of abuse and continue to be victims of domestic and other violence through adulthood.f High utilization of medical and psychiatric health care services is common and costly.g BPD also is associated with substantial psychiatric comorbidity, particularly mood and anxiety disorders, substance use disorders, eating disorders, and other Axis II disorders.h,i
Persons with BPD experience intense dysphoria and intrapsychic pain. Characteristic features include affective intensity, reactivity, and lability; a pervasive pattern of unstable interpersonal relationships; marked behavioral impulsivity; unstable self-identity; intense anger; and extreme fear of abandonment.j
The symptom that probably makes the greatest demand on mental health resources is recurrent suicidal threats/attempts or episodes of self-mutilation, many prompted by disappointment in a relationship.k Two-thirds to three-quarters of BPD patients will attempt suicide, with up to 10% eventually completing suicide, often following multiple failed treatments.l
References
a. Gunderson J. Borderline personality disorder: A clinical guide. 2nd ed. Washington, DC: American Psychiatric Publishing; 2008.
b. Widiger TA, Frances AJ. Epidemiology, diagnosis, and co-morbidity of borderline personality disorder. In: Tasman A, Hales RE, Frances AJ (eds). American Psychiatric Press Review of Psychiatry, vol. 8. Washington, DC: American Psychiatric Press; 1989:8-24.
c. Swartz MS, Blazer D, George L, et al. Estimating the prevalence of borderline personality disorder in the community. J Personal Disord. 1990;4:257-272.
d. Nakao K, Gunderson JG, Phillips KA, et al. Functional impairment in personality disorders. J Personal Disord. 1992;6:24-31.
e. Skodol AE, Gunderson JG, McGlashan TH, et al. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry. 2002;159:276-283.
f. Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatr Clin North Am. 2000;23:89-101.
g. Bender DS, Dolan RT, Skodol AE, et al. Treatment utilization by patients with personality disorders. Am J Psychiatry. 2001;158:295-302.
h. Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis I co-morbidity of borderline personality disorder. Am J Psychiatry. 1998;155:1733-1739.
i. Zimmerman M, Coryell W. DSM-III personality disorder diagnoses in a non-patient sample: demographic correlates and co-morbidity. Arch Gen Psychiatry. 1989;46:682-689.
j. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 1994.
k. Paris J. Social factors in personality disorders— a biopsychosocial approach to etiology and treatment. New York, NY: Cambridge University Press; 1996.
l. Soloff PH, Lynch KG, Kelly TM. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry. 2000;157:601-608.