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Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.

Objective-Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial.Method-Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis.Results-Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups.Conclusions-STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.The treatment of patients with borderline personality disorder is challenging (1, 2). The use of medication has increased, but while several drugs have proven useful, their benefit has been modest (3-4). A range of psychotherapies has been developed and several have NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript garnered empirical support (5-12), including dialectical behavioral therapy (5-7, 12), mentalization-based therapy (8, 9), cognitive behavioral therapy (10), schema-focused therapy (11), and transference-focused therapy (12).In 1995, Blum et al. developed Systems Training for Emotional Predictability and Problem Solving (STEPPS) based on a program introduced by Bartels and Crotty (13). STEPPS is a group treatment that combines cognitive behavior elements and skills training with a systems component for individuals with whom a patient regularly interacts (14,15). STEPPS is easily learned and efficiently delivered by therapists of varying educational and professional backgroun...

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A new self-rated scale to measure severity and change in persons with borderline personality disorder (BPD) is described. The Borderline Evaluation of Severity Over Time (BEST) was developed to rate the thoughts, emotions, and behaviors typical of BPD. Data were collected in the course of a randomized controlled trial (RCT) of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for subjects with BPD. The instrument showed moderate test-retest reliability, high internal consistency, and high discriminant validity. Its 15 separate items showed a moderate or better correlation with the total score. The BEST was also sensitive to clinical change as early as week 4 of the RCT and correlated highly with other measures of illness severity. We conclude that the new scale is both reliable and valid in measuring severity and change in persons with BPD.