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Release: Nov. 4, 2002

$1.7 million NIH grant funds UI study of borderline personality disorder treatment

People with borderline personality disorder have difficulty managing highly charged emotions and can experience self-damaging or impulsive behaviors, suicidal thoughts and rapidly changing reactions toward others in their life. Current standard treatment for the condition -- medication and individualized psychotherapy -- often does not help people improve sufficiently to lead full lives.

However, University of Iowa Health Care researchers have received a $1.7 million, four-year grant from the National Institute of Mental Health, part of the National Institutes of Health, to study the effectiveness of a new cognitive therapy group treatment. The approach is supplemental to standard care and involves helping patients with borderline personality disorder learn how to change their behavior. The award was effective in July, and the UI team is getting ready to involve its first groups of participants.

The treatment under investigation is known as Systems Training for Emotional Predictability and Problem-Solving (STEPPS) and focuses on making connections between how a person thinks and their feelings and behaviors, said Nancee Blum, a project coordinator in the UI Department of Psychiatry and study co-investigator. The study's principal investigator is Donald Black, M.D., UI professor of psychiatry.

The UI study will include a total of 160 adult participants who already are diagnosed with borderline personality disorder, which is also described as an emotional intensity disorder. Comparisons will be made between paired groups in which one group of 10 individuals receives usual treatment plus STEPPS over a five-month period and another group of 10 individuals receives only usual treatment over the same time period. There also will be a one-year follow up to see if patients are maintaining their progress.

"Psychiatry doesn't know a lot about treating borderline personality disorder," Black said. "Based on our earlier work, we think the STEPPS method might offer a new advance in treating this very difficult illness."

The program aims to teach emotional regulation and behavioral lifestyle skills to help people better manage their disorder, such as how to deal with anger and not see things only in terms of "black and white."

Blum said that underlying the approach is the goal of giving those who interact with or treat a person with the disorder a "common language" to talk about the condition and its management.

"The 'systems training' component refers to the fact that we are not only teaching patients with the disorder this skill but also teaching the skills to those people with whom the patients regularly interact and with whom they share information about their disorder," Blum explained.

A patient's "system" contacts can include mental health practitioners, family members, significant others, friends, clergy and even employers, said Blum, who was instrumental in developing STEPPS.

STEPPS is used at the UI and several other sites in Iowa and other states. In addition, institutions in the Netherlands have widely used the program. These uses suggest that people can get better using the highly structured model and that hospitalizations are decreased.

Blum said the STEPPS treatment model is based on ideas by Norman Bartels, a clinician in Wheaton, Ill. Blum read a treatment manual Bartels had written about a systems approach to borderline personality disorder and met with him in the early 1990s to observe his work.

Blum then developed an expanded cognitive therapy approach and wrote a more detailed treatment manual. Don St. John, UI physician assistant in psychiatry, and Bruce Pfohl, M.D., UI professor of psychiatry and preventive medicine, then helped Blum further develop the approach. More recently, Black proposed to Blum that the UI pursue a study of the treatment. St. John and Pfohl also are co-investigators for the NIHM grant the team applied for and was awarded.

Black said it is difficult to know exactly what causes borderline personality disorder. "Borderline personality disorder could be related to maltreatment during childhood, and some components of the condition probably are genetic, but for the most part we don't know why people develop the condition," he said.

Borderline personality disorder is commonly diagnosed in persons between ages 18 and 25. Women are three times more likely than men to be diagnosed with the condition. Nationwide, individuals with the condition account for approximately 20 percent of mental health in-patient treatments.

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