A Cognitive Group Treatment for Borderline Outpatients

该项目的目的是测试一种新的基于认知行为系统的群体治疗边缘型人格障碍（BPD）患者的疗效，并将其与“常规治疗”（TAU）进行比较。我们选择修改最初由巴特尔斯和克罗蒂开发的程序。这导致我们开发了STEPPS，这是一个缩写，代表情感可预测性和解决问题的系统训练。简而言之，该计划包括认知行为技术和技能训练与系统组件相结合；后者涉及BPD患者及其系统内的人，包括家庭成员、朋友和卫生保健专业人员。STEPPS包括20个2小时的小组会议，由两名主持人主持；该疗法以手册为基础，每周设定具体目标。我们建议在项目的前两年半招募大约160名患有DSM-IV BPD的成年人。受试者将通过地区心理学家、精神科医生、心理健康诊所和医院的转诊招募。受试者将使用修订的边缘型人格障碍诊断访谈（DIB-R）和DSM-IV人格障碍结构化访谈（SIDP-IV）的相关部分进行筛选。符合特定纳入/排除标准的适当受试者将随机分配到STEPPS或TAU。两组的受试者将被允许继续看他们的精神科医生，服用精神药物，并继续进行其他治疗。基线评估将包括DSM-IV的结构化临床访谈、SIDP- IV、Hollingshead量表、社会适应量表、Beck抑郁量表、积极和消极情感量表、症状检查表-90- r、巴雷特冲动量表和医疗结果研究简短健康调查。一种新的自评量表，随着时间的严重程度的边缘评估（BEST），也将被用于评定BPD症状。受试者将在基线、第4、8、12、16和20周进行评估。非专业和专业支持系统成员（举报人）将被要求每隔一段时间对受试者的进度进行评估。在试验结束时，将对举报人和受试者评估STEPPS和TAU的满意度。将通过定期监督和对录像的盲目评分来保持治疗的保真度。随机分配到STEPPS的受试者将在研究完成后的第1、3、6、9和12个月进行随访。我们假设参与STEPPS的受试者比接受TAU的受试者有更好的症状改善；改善将包括更大的情绪稳定性，更少的故意自残，更少的愤怒/冲动，更低的医疗保健使用率。我们假设STEPPS的收益将维持1年以上。这些发现应该增加我们对BPD的适当临床管理的理解。如果STEPPS的疗效得到证实，未来的研究将包括更大的样本，以帮助测试特定的亚组是否会优先反应，并将STEPPS与其他项目（包括辩证行为疗法）进行比较。

The goal of this project is to test the efficacy of a new cognitive-behavioral systems-based group treatment for persons with borderline personality disorder (BPD) and to compare it to "treatment as usual" (TAU). We elected to modify a program originally developed by Bartels and Crotty. This led us to develop STEPPS, an acronym that stands for Systems Training for Emotional Predictability and Problem Solving. Briefly, the program involves both cognitive-behavioral techniques and skills training combined with a systems component; the latter involves the patients with BPD and those in their system, including family members, friends, and health care professionals. STEPPS involves twenty 2-hour group meetings with two facilitators; the therapy is manual-based and each week specific goals are set. We propose to recruit approximately 160 adults with DSM-IV BPD during the first 2 1/2 years of the project. Subjects will be recruited through referral from area psychologists, psychiatrists, mental health clinics, and hospitals. Subjects will be screened using the Revised Diagnostic Interview for Borderlines (DIB-R) and relevant sections of the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Appropriate subjects meeting specified inclusion/exclusion criteria will be randomized to STEPPS or TAU. Subjects in both groups will be allowed to continue to see their psychiatrist, take psychotropic medication, and continue with other therapy. Baseline assessments will include the Structured Clinical Interview for DSM-IV, the SIDP- IV, the Hollingshead Scale, the Social Adjustment Scale, the Beck Depression Inventory, the Positive and Negative Affectivity Scale, the Symptom Checklist-90-R, the Barrett Impulsivity Scale, and the Medical Outcomes Study Short Form Health Survey. A new self-rated scale, the Borderline Evaluation of Severity Over Time (BEST), will also be used to rate BPD symptoms. Subjects will be assessed at baseline, and at weeks 4, 8, 12, 16, and 20. Lay and professional support system members (informants) will be asked to rate the subjects progress at specified intervals. Satisfaction with STEPPS and TAU will be assessed in informants and subjects at the conclusion of the trial. Therapy fidelity will be maintained through regular supervision, and blind ratings of videotaped sessions. Subjects randomized to STEPPS will be followed up at months 1, 3, 6, 9, and 12 post-study completion. We hypothesize that subjects participating in STEPPS will have better symptomatic improvement than subjects receiving TAU; improvement will include greater mood stability, less deliberate self-harm, less anger/impulsivity, and lower rates of health care utilization. We hypothesize that the gains of STEPPS will be maintained over 1 year. These findings should add to our understanding of the appropriate clinical management of BPD. If the efficacy of STEPPS is confirmed, future studies will include larger samples to help test whether specific subgroups will preferentially respond, and comparisons of STEPPS to other programs, including Dialectical Behavior Therapy.