Borderline Evaluation Of Severity Research Articles

A Cross-Sectional Study on Outcomes of Hospitalization in Patients with Borderline Personality Disorder After Six Months

Background: Borderline Personality Disorder (BPD) is a serious psychiatric disorder that is characterized by unstable affect, mood, behavior, object relations, and self-image. In this study, a 6-month follow-up was performed to evaluate the outcomes of hospitalization in terms of symptoms severity, suicidal attempts, self-harm behaviors, substance use, and anger expression.
 Methods: This cross-sectional study was performed on 60 patients hospitalized with BPD in Iran Psychiatric Hospital in the first 6 months of 2018. Demographic information of patients was collected at the time of admission. Patients were assessed by initial psychiatric evaluations with the Structured Clinical Interview for DSM-IV [Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-1), Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-2)], the Borderline Evaluation of Severity over Time (BEST), the Spielberger’s state-trait anger expression inventory and Depression Anxiety Stress Scale (DASS). Medical comorbidities, self-harm and suicide ideations and attempts, high-risk behaviors, and substance use disorders were also assessed and recorded. Three months after discharge, the patients were reassessed by BEST questionnaire and after 6 months, they were reassessed using DASS, BEST, SCID-2, and Spielberger’s state-trait anger expression inventory.
 Results: The repeated measures analysis of changes in quantitative variables including the scores of the severity of symptoms in BEST, DASS, and Spielberger tools showed that the scores of DASS decreased significantly during the study (p=0.020), while no significant change was observed in the scores of Spielberger and BEST inventory.
 Conclusion: In patients with BPD, hospitalization was correlated with reduced depression, anxiety, and stress 6 months after discharge. Regular follow-ups along with regular patient visits can form an effective therapeutic relationship with the patients and help to improve monitoring of their drug usage, self-harming acts, and suicidal thoughts.

Borderline personality traits are differently associated with postpartum psychosis and postpartum depression episodes in women with bipolar disorder

BackgroundWomen with bipolar disorder have approximately 40 %–50 % chance of having a perinatal bipolar recurrence. Knowing the factors associated will be beneficial for the prediction and prevention of episodes. We aim to establish if borderline personality disorder traits, as measured by the BEST (Borderline Evaluation of Severity over Time) scale, are associated with perinatal psychiatric outcomes. MethodsWe recruited women with bipolar disorder as part of the BDRN (Bipolar Disorder Research Network) study. Women were interviewed and we collected their demographic and clinical information. Participants subsequently completed the BEST questionnaire. We analysed the association of BEST scores with lifetime presence/absence of perinatal bipolar relapse and, employing multinomial logistic regression, with different subtypes of perinatal outcomes: postpartum psychosis; postpartum depression, and other episodes. ResultsIn our sample of 807, although there was no significant association between the BEST total score and perinatal episodes as a whole (adjustedOR 1.01 CI95% [0.99, 1.03], p = 0.204), we found significant differing associations with different subtypes of episodes. Women scoring highly on BEST were less likely to experience a postpartum psychotic episode (RRR 0.96 CI95% [0.94, 0.99], p = 0.005) but more likely to experience a non-psychotic depressive episode (RRR 1.03 CI95% [1.01, 1.05], p = 0.007) than no relapse. LimitationsThis study is limited by its cross-sectional design and self-report nature of BEST. ConclusionsIn women with bipolar disorder, borderline traits differentiate the risk of postpartum depression and postpartum psychosis, emphasise the importance of considering risk factors for these perinatal episodes separately, and may help individualise the risk for women in the perinatal period.

Online Sexual Activity among Iranian Clients with Borderline Personality Disorder and Its Correlation with Severity of Symptoms.

Objective: Clients with borderline personality disorder (BPD) often engage in high-risk sexual behaviors. Online sexual platforms convey abusive and harmful themes, especially for this group of sexually impulsive patients. We hypothesized a correlation between their online sexual activities and the severity of BPD symptoms. Method : Fifty clients with BPD who were referred to Iran psychiatric hospital and Tehran Psychiatric Institute in 2020 participated in this research. The Borderline Evaluation of Severity over Time (BEST) questionnaire was used to assess the severity of BPD symptoms, and the Internet Sex Screening Test (ISST) was used to evaluate online sexual behaviors. A psychiatric interview considered substance abuse and other confounding factors. Results: The mean ISST and BEST scores were 7.82 ± 5.74 and 41.7 ± 12.5, respectively. There was a positive and significant correlation between the severity of BPD symptoms and online sexual activities (P < 0.001, r = 0.480). There was also a significant relationship between online sexual activities and a history of substance abuse (P = 0.003, F = 25.06). Conclusion: Online sexual activity can harm clients with BPD who are more vulnerable to high-risk sexual behaviors. More severe borderline personality traits were associated with more online sexual activity, which underlines the importance of providing education about and managing such activities in clients with BPD.

Factor structure of borderline personality disorder and response to Systems Training for Emotional Predictability and Problem Solving

Differential response to the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program was compared in subgroups identified through latent class analysis (LCA). STEPPS is an evidence-based group treatment program for patients with borderline personality disorder (BPD). A reanalysis of data was conducted using data from a 20-week randomized controlled trial and 1-year follow-up. Subjects (n = 164) with DSM-IV BPD were assessed for comorbid Axis I and II disorders and selected clinical variables. Severity was assessed using the Zanarini Rating Scale for BPD (ZAN-BPD) and the Borderline Evaluation of Severity Over Time (BEST). Three- and four-class models were identified with the four-class model having the better fit. The latter included a high severity (HS) class (26%), an affective instability/substance abuse (AISA) class (16%), an empty/dissociation/identity disturbance (EDID) class (27%), and a low severity (LS) class (30%). High impulsiveness predicted membership in the HS class. Improvement was determined using a linear mixed-effects model. Those most likely to benefit were those in the HS group characterized by high symptom severity, Axis I and II comorbidity, problem relationships, abandonment fears, and intense anger. This work should help further efforts to match patients with treatments based on sociodemographic, diagnostic, and other illness characteristics.

Psychoeducation for borderline personality difficulties: a preliminary study

PurposeNational Institute for Clinical and Health Excellence guidelines (2009) state that low intensity psychological interventions should not be used for borderline personality disorder. However, an emerging body of evidence suggests brief interventions such as psychoeducation may be relevant for those presenting with borderline personality difficulties. The purpose of this study is to evaluate the benefit of learning about thinking, emotions and relationships (LATER), a co-produced psychoeducation programme for borderline personality difficulties in a community-based setting.Design/methodology/approachParticipants (n = 125) self-referred to LATER, a group-based psychoeducation programme delivered at the [NHS Trust] Recovery College. Participants were assessed pre- and post-intervention using the tailor-made psychological education group evaluation scale, the borderline evaluation of severity over time and work and social adjustment scale. Paired t-tests were conducted on pre- and post-scores, and effect sizes were calculated.FindingsAfter LATER, participants reported a significant decrease in negative thoughts and feelings, destructive behaviours and overall borderline symptom severity, but no significant increase in positive behaviours. Significant decreases were found in areas of work and social impairment. Participants’ overall understanding of personality difficulties significantly improved. Effect sizes were small to moderate.Research limitations/implicationsLimitations of the study include the lack of a control group, adjustment for confounders and follow-up. Replication with a more robust methodology is needed.Originality/valueThis study contributes to the evidence for the usefulness of brief interventions for personality difficulties, particularly in the context of a stepped model of care and adds to the research on co-production.

STEPPS for Borderline Personality Disorder: A Pragmatic Trial and Naturalistic Comparison With Noncompleters.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group psychotherapy approach that is effective for patients with borderline personality disorder (BPD) in a public health care setting. The sample in this study comprised 118 outpatients with BPD who were asked to participate in a Spanish-adapted version of STEPPS for 18 months, a psychotherapy program that could be added to their usual psychiatric intervention. They were divided into an experimental group who participated in STEPPS, and a control group, who received treatment as usual. Several variables were collected and the Borderline Evaluation of Severity Over Time (BEST) scale was administered at pretest, Months 3 and 6, posttest (Month 18), and 2-year follow-up (Month 42), after which a post hoc data analysis was carried out. The STEPPS program improved the as-usual treatment provided previously, and the results were cost-effective. A higher educational level and good patient collaboration predicted better outcome.

Improvement in borderline personality disorder symptomatology after repetitive transcranial magnetic stimulation of the dorsomedial prefrontal cortex: preliminary results.

Objective:Current treatment for borderline personality disorder (BPD) involves psychological and pharmacological interventions. However, neuromodulation techniques such as repetitive transcranial magnetic stimulation (rTMS) may positively affect BPD symptomatology. The objective of this study was to evaluate the clinical and neuropsychological effects of rTMS on the dorsomedial prefrontal cortex (DMPFC) in BPD patients.Methods:Fourteen patients with BPD were randomized into two groups (active vs. sham) for 15 sessions of rTMS on the DMPFC. Clinical effects were measured using the Borderline Symptoms List (BSL), Clinical Global Impression Scale for BPD (CGI-BPD), Borderline Evaluation of Severity over Time (BEST), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Barratt’s Impulsiveness Scale (BIS). Neuropsychological effects were determined by a Stop-Signal Task (SST), the Wisconsin Card-Sorting Test (WCST), and the Iowa Gambling Test (IGT).Results:Within-group comparison showed significant differences (p < 0.05) in CGI-BPD (total score and six of nine psychopathologic domains), BEST, HDRS, HARS, and IGT scores for active modality.Conclusion:The 5 Hz-DMPFC rTMS technique was well tolerated and lessened the severity of BPD symptomatology, especially abandonment, affective issues, interpersonal relationships, suicidal behavior, anger, and paranoid ideation. Cognitive improvement was seen in decision-making. Additional studies are needed to fully evaluate the effects of rTMS on BPD symptomatology.Clinical Trial Registration:NCT03832777.

Neuropsychological deficits correlate with symptoms severity and cortical thickness in Borderline Personality Disorder

BackgroundNeuropsychological abnormalities have been proposed to contribute to the development and maintenance of Borderline Personality Disorder (BPD). Previous meta-analyses and reviews confirmed deficits in a broad range of cognitive domains, including attention, cognitive flexibility, memory, executive functions, planning, information processing, and visuospatial abilities, often suggested to underlie brain abnormalities. However, no study directly explored the structural neural correlates of these deficits in BPD, also accounting for the possible confounding effect of pharmacological treatments, often used as adjunctive symptom-targeted therapy in clinical setting. MethodsIn this study we compared the performance of 24 BPD patients to 24 healthy controls obtained at the neuropsychological battery “Brief Assessment and Cognition in Schizophrenia”, exploring the relationship between the cognitive impairments and current symptomatology, brain grey matter volumes and cortical thickness, controlling for medications load. ResultsData revealed deficits in verbal memory and fluency, working memory, attention and speed of information processing and psychomotor speed and coordination when medication load was not in the model. Correcting for this variable, only the impairment in psychomotor abilities remained significant. A multiple regression confirmed the effect of this neuropsychological domain on the severity of BPD symptomatology (Borderline Evaluation of Severity Over Time). In BPD, the performance at psychomotor speed and coordination was also directly associated to cortical thickness in postcentral gyrus. LimitationsRelatively small sample size, especially for neuroimaging. ConclusionsOur study highlighted an influence of BPD neuropsychological impairments on symptomatology, and cortical thickness, prompting the potential clinical utility of a cognitive remediation program in BPD.

The influence of borderline personality traits on clinical outcomes in bipolar disorder.

Systematic reviews suggest comorbid borderline personality disorder is present in approximately 20% of individuals who have bipolar disorder, but current diagnostic systems demonstrate a move towards dimensional rather than categorical approaches to classifying personality pathology. We aimed to examine the presence and severity of borderline personality traits in bipolar I and bipolar II disorder, and to explore associations between the presence/severity of borderline personality traits and clinical outcomes in bipolar disorder. Borderline personality traits were measured in 1447 individuals with DSM-IV bipolar disorder (1008 bipolar I disorder and 439 bipolar II disorder) using the Borderline Evaluation of Severity over Time (BEST) questionnaire. Lifetime clinical outcomes were assessed via Schedules for Clinical Assessment in Neuropsychiatry (SCAN) semi-structured interview and clinical case notes. Borderline personality traits were common in both bipolar disorder groups, with 86.2% participants reporting at least one trait. These included traits that overlap with (eg mood instability) and those that are distinct from the symptoms of bipolar disorder (eg fear of abandonment). Borderline personality traits were significantly more frequent and more severe in bipolar II disorder compared to bipolar I disorder. More severe borderline traits, and even the presence of a single borderline personality trait, were significantly associated with younger age of bipolar disorder onset and higher prevalence of lifetime alcohol misuse in both bipolar disorder groups. The presence of comorbid borderline personality traits should be considered in the management of all patients with bipolar disorder irrespective of whether criteria for a categorical borderline personality disorder diagnosis are met.

Comorbid personality disorders and their impact on severe dissociative experiences in Mexican patients with borderline personality disorder

Objective: To identify personality disorders comorbid with borderline personality disorder (BPD) that may confer greater risk for the presence of severe dissociative experiences.Method: Three hundred and one outpatients with a primary diagnosis of BPD were evaluated using the Structured Clinical Interview for DSM-IV Axis II personality disorders, the Borderline Evaluation of Severity Over Time (BEST) and the Dissociative Experiences Scale (DES).Results: The most frequent personality disorders comorbid to BPD were paranoid (83.2%, n = 263) and depressive (81.3%, n = 257). The mean BEST and DES total score were 43.3 (SD = 11.4, range 15–69) and 28.6 (SD = 19.8, range 0–98), respectively. We categorized the sample into patients with and without severe dissociative experiences (41% were positive). A logistic regression model revealed that Schizotypal, Obsessive-compulsive and Antisocial personality disorders conferred greater risk for the presence of severe dissociative experiences.Discussion: Our results suggest that a large proportion of patients with BPD present a high rate of severe dissociative experiences and that some clinical factors such as personality comorbidity confer greater risk for severe dissociation, which is related to greater dysfunction and suffering, as well as a worse progression of the BPD.

Neuro-Cognitive Remediation of Emotion Processing in Patients with Borderline Personality Disorder through Psychotherapy

Dynamic Deconstructive Psychotherapy has used neuroscience findings to propose the specific neuroaffective deficits in processing the emotional experiences as etiology of the borderline personalitydisorder. The purpose of this study was to evaluate the efficacy of the Dynamic Deconstructive Psychotherapy to improve the symptoms in patients diagnosed with a borderline personality disorder byremediation of neuro-affective defects. This study was designed as a randomized controlled trial using the pre-test, post-test, and control group. Thirty patients who were diagnosed with borderline personalitydisorder meeting the inclusion criteria randomly divided into two groups. Both groups evaluated using both the Borderline Evaluation of Severity over Time (BEST) and Patient Health Questionnaire Mood Scale (PHQ-9) questionnaires at the baseline and the over course of the treatment. Data analysis using repeated measures ANOVA indicated that the effect of measuring time (p=0.001) and time/group (p=0.010) on linear combination of the severity of borderline disorder and depression were significant. This result supports the efficacy of Dynamic Deconstructive Psychotherapy based on the neurocognitive remediation of emotion processing using association, attribution and alterity techniques.

Defense style and dissociative phenomena in patients with borderline personality disorder

Introduction Patients with borderline personality disorder (BPD) are unique and diverse in their pathology, defense style, and clinical presentations. Many of these patients have other personality disorders as well. They tend to display a wide range of other psychiatric disorders, including dissociative phenomena and experiences. Patients and methods A total of 60 female patients were diagnosed with BPD using the Diagnostic and Statistical Manual of Mental Disorders, IV ed. Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Severity of illness and emotional and behavioral aspects of patients were assessed using Borderline Evaluation of Severity over Time. Defense style of patients was assessed using the Defense Style Questionnaire. Dissociative phenomena were studied using the Dissociative Experience Scale (DES). Results The most commonly used defenses by the study patients were undoing, idealization, somatization, and splitting. Patients with absent criteria 4 (impulsivity) and 7 (feeling of emptiness) of BPD significantly displayed more mature defenses, whereas patients having criterion 9 (paranoid ideation and severe dissociation) of BPD significantly displayed neurotic type of defenses. Mature defenses were significantly negatively correlated with the absorption and depersonalization factors of DES. Neurotic defenses were significantly correlated with the total score of DES, absorption, and depersonalization factors. Immature defenses were significantly correlated only with the depersonalization factor of DES. Conclusion Patients with BPD have a specific pattern of defense style that might be linked to their specific illness criteria. Displaying certain phenomena of dissociation might be related to the particular pattern of the dominant defense mechanisms in these patients.

STEPPS treatment programme for borderline personality disorder: Which scale items improve? An item-level analysis.

We examined which items on the Borderline Evaluation of Severity Over Time and the Zanarini Rating Scale for Borderline Personality Disorder improved during participation in Systems Training for Emotional Predictability and Problem Solving (STEPPS). Data on 193 subjects from two independent sources were included: (1) a randomized controlled trial at an academic medical centre and (2) uncontrolled data from Iowa's correctional system. STEPPS effect size was estimated by contrasting effect size for those in the randomized controlled trial assigned to STEPPS+treatment as usual to effect size for those assigned to treatment as usual alone. Items from the Borderline Evaluation of Severity Over Time scale showing the greatest improvement assessed affective instability, 'taking steps to avoid/prevent problems', 'choosing to use a positive activity', identity disturbance and abandonment fears. The Zanarini Rating Scale for Borderline Personality Disorder items showing the greatest improvement assessed mood instability, chronic feelings of emptiness and identity disturbance. STEPPS effect size was significant for the Borderline Evaluation of Severity Over Time items rating paranoia and 'taking steps to avoid/prevent problems' and the Zanarini Rating Scale for Borderline Personality Disorder items assessing paranoia, impulsivity, chronic emptiness and unstable relationships. This, and future work, could eventually help in matching patients to particular treatment programmes that target their preponderant symptoms. © 2018 John Wiley & Sons, Ltd.

Clinical improvement in patients with borderline personality disorder after treatment with repetitive transcranial magnetic stimulation: preliminary results.

Objective:Current treatment of borderline personality disorder (BPD) consists of psychotherapy and pharmacological interventions. However, the use of repetitive transcranial magnetic stimulation (rTMS) could be beneficial to improve some BPD symptoms. The objective of this study was to evaluate clinical improvement in patients with BPD after application of rTMS over the right or left dorsolateral prefrontal cortex (DLPFC).Method:Twenty-nine patients with BPD from the National Institute of Psychiatry, Mexico, were randomized in two groups to receive 15 sessions of rTMS applied over the right (1 Hz, n=15) or left (5 Hz, n=14) DLPFC. Improvement was measured by the Clinical Global Impression Scale for BPD (CGI-BPD), Borderline Evaluation of Severity Over Time (BEST), Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HAM-A), and Barratt Impulsiveness Scale (BIS).Results:Intragroup comparison showed significant (p < 0.05) reductions in every psychopathologic domain of the CGI-BPD and in the total scores of all scales in both groups.Conclusions:Both protocols produced global improvement in severity and symptoms of BPD, particularly in impulsiveness, affective instability, and anger. Further studies are warranted to explore the therapeutic effect of rTMS in BPD.Clinical trial registration:NCT02273674.

Normative data and factorial structure of the Turkish version of the Borderline Evaluation of Severity over Time (BEST)

ABSTRACTObjective: Borderline Personality Disorder is a psychiatric condition, which is characterized by unstable interpersonal relationships, fear of abandonment, difficulties in regulating emotions, feeling of emptiness, chronic dysphoria and depression, and impulsivity and increased risk-taking behaviors. In this study, we aimed to translate and establish psychometric properties and factorial validity of the Borderline Evaluation of Severity over Time (BEST) in a representative Turkish university students sample and obtain normative data for future epidemiological and clinical studies in Turkey.Methods: Participants were 306 (201 females, 105 males) college students at the Hasan Kalyoncu University in Gaziantep, Turkey. The study protocol was approved by the Ethics Committee of Hasan Kalyoncu University. Sociodemographic information of the participants was collected and Turkish version of the BEST, the Turkish version of the Borderline Personality Questionnaire (BPQ), Beck Depression Inventory (BDI), P...

Digging out insights and behavioral correlates of false and true femininity in borderline personality disorder patients attending four-step integrative model group psychotherapy

IntroductionThe four-step integrative model of psychotherapy is concerned with individual's needs, wants, rights and decisions in that order. It may carry a promise for deep and changing vision for patients with borderline personality disorder (BPD).ObjectivesThe study of the illuminating and changing effect of dealing with BPD patients in view of their needs, wants, rights and decisions.AimsTo evaluate the effect of group work through the hierarchy of the four-step integrative model with BPD patients and to help them explore false and true elements of their femininity.MethodsForty-three female patients (age range: 19-37) diagnosed according to DSM-IV diagnostic criteria for BPD were enrolled in a dynamic psychotherapy group. Their progress was evaluated using Borderline evaluation of severity over time (BEST) and they wrote down detailed comments about their experience quarterly.ResultsResults of regular attendants for 2 years were included (35 = 81.4%). The results of BEST showed a significant reduction of BPD severity at the end of 1 and 2 years. During psychotherapy sessions and within their quarterly comments, patients expressed their change in terms of moving from a state of cunning, manipulation, aggression, arrogance, envy and rejection (as stemming from their false femininity) into wisdom, confrontation, patience, pride, healthy competition and containment respectively (as stemming from their true femininity).ConclusionsPatients with BPD may gain a better insight and genuine change as they realize what is false and what is true about their femininity in the context of attending four-step integrative model group psychotherapy.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Poster #190 AUDITORY VERBAL HALLUCINATIONS IN PATIENTS WITH BORDERLINE PERSONALITY DISORDER ARE SIMILAR TO THOSE IN SCHIZOPHRENIA

Neuropsychological abnormalities have been proposed to contribute to the development and maintenance of Borderline Personality Disorder (BPD). Previous meta-analyses and reviews confirmed deficits in a broad range of cognitive domains, including attention, cognitive flexibility, memory, executive functions, planning, information processing, and visuospatial abilities, often suggested to underlie brain abnormalities. However, no study directly explored the structural neural correlates of these deficits in BPD, also accounting for the possible confounding effect of pharmacological treatments, often used as adjunctive symptom-targeted therapy in clinical setting.In this study we compared the performance of 24 BPD patients to 24 healthy controls obtained at the neuropsychological battery “Brief Assessment and Cognition in Schizophrenia”, exploring the relationship between the cognitive impairments and current symptomatology, brain grey matter volumes and cortical thickness, controlling for medications load.Data revealed deficits in verbal memory and fluency, working memory, attention and speed of information processing and psychomotor speed and coordination when medication load was not in the model. Correcting for this variable, only the impairment in psychomotor abilities remained significant. A multiple regression confirmed the effect of this neuropsychological domain on the severity of BPD symptomatology (Borderline Evaluation of Severity Over Time). In BPD, the performance at psychomotor speed and coordination was also directly associated to cortical thickness in postcentral gyrus.Relatively small sample size, especially for neuroimaging.Our study highlighted an influence of BPD neuropsychological impairments on symptomatology, and cortical thickness, prompting the potential clinical utility of a cognitive remediation program in BPD.

Effectiveness of Adjunctive STEPPS Group Treatment in Borderline Personality Disorder Patients

Back to table of contents Previous article Next article Letters to the EditorFull AccessEffectiveness of Adjunctive STEPPS Group Treatment in Borderline Personality Disorder PatientsOLAF SCHULTE-HERBRÜGGEN M.D.JOHANNA KOERTING M.Sc.STEFAN ROEPKE M.D.,OLAF SCHULTE-HERBRÜGGEN M.D.Search for more papers by this authorJOHANNA KOERTING M.Sc.Search for more papers by this authorSTEFAN ROEPKE M.D.Search for more papers by this author,Published Online:1 Oct 2008https://doi.org/10.1176/appi.ajp.2008.08030390AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the April 2008 issue of the Journal , Nancee Blum, M.S.W., et al. (1) reported the positive effects of a 20-week Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment compared with that of standard therapy (including individual psychotherapy and psychotropic medication) but no additional group treatment. Patients with borderline personality disorder were assessed on several core symptoms and emergency department visits. STEPPS has been presented as a broad approach, which includes numerous components of well-established manualized psychotherapies, such as dialectical behavior therapy, shown to be effective in the treatment of borderline personality disorder (2 , 3) . However, several factors in the study conducted by Blum et al. remain unclear, and further explanation may help to better support their conclusions of an effective psychotherapeutic intervention.First, more patients in the STEPPS group received individual psychotherapy compared with patients in the standard condition group. In addition, individual therapists were informed about the STEPPS program. To clearly define the effect of STEPPS, it would have been helpful to know the degree to which each individual therapist integrated elements of the program into therapy treatment.Second, the authors stated that improvement for the treatment as usual group alone appeared to be mostly confined to the first half of the treatment period. This conclusion seems premature, since Borderline Evaluation of Severity Over Time Scale scores and Clinical Global Impression (CGI) ratings showed benefits of STEPPS only within the last 4 weeks of treatment, whereas no data were presented for most primary and secondary outcome measures for weeks 12 or 16. Important amelioration of psychopathology with the discontinuation of therapy is particularly surprising, since our experience with dialectical behavior therapy has shown that there is, in most cases, a tendency for a patient’s symptoms to worsen before leaving the therapy, reflecting the patient’s fear of falling back into dysfunctional behavior. Since patients with borderline personality disorder are rather sensitive to changes in interpersonal relations, this paradox effect between weeks 16 and 20 should be assessed in future studies using STEPPS. Third, dialectical behavior therapy has been repeatedly shown to reduce suicide attempts and self-harm (2 , 3) . It would be interesting to learn of the exact number of suicide attempts and self-harm acts in both groups. Last, the 1-year follow-up analysis should have included baseline values prior to treatment, which would have allowed for observation of any positive treatment effects of data for week 72, as opposed to the absence of significant symptom worsening between weeks 20 and 72.Berlin, GermanyThe authors report no competing interests.This letter (doi: 10.1176/appi.ajp.2008.08030390) was accepted for publication in July 2008.