A Cognitive Group Treatment for Borderline Outpatients

本项目的目标是测试一种新的基于认知行为系统的团体治疗对边缘性人格障碍(BPD)患者的疗效，并将其与“照常治疗”(TAU)进行比较。我们决定修改一个最初由Bartels和Crotty开发的程序。这导致我们开发了STEPPS，这是系统培训的首字母缩写，用于情感预测和解决问题。简而言之，该计划包括认知-行为技术和技能培训，并结合系统组件；后者涉及BPD患者和他们系统中的患者，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，有两名辅导员；治疗是基于手动的，每周都会设定具体的目标。我们建议在该项目的头两年半内招募大约160名患有DSM-IV BPD的成年人。受试者将通过地区心理学家、精神病学家、心理健康诊所和医院的转介来招募。受试者将使用修订的边缘诊断面谈(DIB-R)和DSM-IV人格障碍结构化面谈(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被随机分配到STEPPS或TAU。两组的受试者都将被允许继续去看他们的精神医生，服用精神药物，并继续接受其他治疗。基线评估将包括DSM-IV的结构化临床访谈、SIDP-IV、Hollinghead量表、社会适应量表、Beck抑郁量表、积极和消极情感量表、症状自评量表-90-R、Barrett冲动量表和简式健康调查。一种新的自我评估量表，即随时间推移的严重性边缘评估(BEST)，也将用于对BPD症状进行评级。受试者将在基线以及第4、8、12、16和20周进行评估。外行和专业支持系统成员(告密者)将被要求以指定的间隔对受试者的进展进行评级。在试验结束时，将对举报人和受试者进行对STEPPS和TAU的满意度评估。治疗的保真度将通过定期监督和对录像治疗过程的盲目评级来保持。被随机分为STEPPS的受试者将在研究完成后的1、3、6、9和12个月进行随访。我们假设，参加STEPPS的受试者将比接受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，以及更低的卫生保健利用率。我们假设Stepps的收益将保持在1年以上。这些发现将增加我们对BPD的适当临床处理的理解。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，以及STEPPS与其他项目的比较，包括辩证行为疗法。

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.