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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.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is an evidence-based group treatment program for ambulatory patients with borderline personality disorder (BPD). The program was introduced to the Iowa correctional system in 2005, and groups have been ongoing ever since. In this analysis, we examine whether response to the STEPPS program differs based on sex, age (< 40/≥ 40 years), or race/ethnicity (minority/non-minority) using data collected in Iowa prisons and in community corrections. Subjects were recruited and assessed by correctional staff. Offenders with BPD were offered the opportunity to participate in the STEPPS program. The presence of BPD was assessed using a module from the Structured Interview for DSM-IV Personality. Efficacy assessments included the Borderline Evaluation of Severity Over Time Scale, the Beck Depression Inventory, and the Positive and Negative Affectivity Scale. The Client Satisfaction Questionnaire-8 assessed program satisfaction. Data on 77 offenders were analyzed. All participated in the STEPPS program and 53% completed all 20 weeks. The analysis showed that there were no significant differences in response to STEPPS in terms of sex, age, or race/ethnicity on any of the three efficacy measures. Women expressed greater satisfaction than men, but there were no differences with regard to age or race/ethnicity. The implications of the findings are discussed.

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.

In this study we present a clinical application of the STEPPS model in an Italian sample of severely affected patients with borderline personality disorder (BPD) or personality disorder (PD) with prominent borderline features in comorbidity with a mood disorder. The aims of this work are: 1) to confirm our preliminary results in a larger sample and at a 12-month follow-up, and 2) to identify predictors of drop-out vs completion of STEPPS in order to understand which characteristics of patients make them suitable or not for this treatment. The sample is composed of 32 subjects recruited from a population of inpatients of the Mood Disorders Center, Department of Clinical Neurosciences, Hospital San Raffaele-Turro, Milan. To confirm STEPPS efficacy at 12-month follow-up, we selected the following outcome criteria: reduction in the number of hospitalizations related to self-harm acts; reduction in the number of suicidal attempts; reduction of perceived emotional intensity levels; changes in cognitive filter scores; changes in the scores on self-report questionnaires. To identify predictors of drop-out vs completion, we analysed the following variables: demographic features (sex, marital status, school level achieved, and job status); Axis-I diagnosis; Axis-II categorical and dimensional diagnosis; and personality features. Seventeen (53%) subjects completed the treatment successfully. The drop-out rate was 47%. Patients who completed the program show a significant decrease in the number of hospitalizations, both at the end of the treatment and at 12-month follow-up. Friedman ANOVA test shows a significant decrease in suicidal attempts during and after STEPPS, and at 12-month follow-up. Analysis of drop-outs showed no significant differences with regard to sex, marital status, school level and job status between the two groups. Axis-I and Axis-II categorical diagnoses did not discriminate between the two groups. Those patients who dropped differ significantly from completers in histrionic personality traits and magical thinking index, given by the interaction between low scores in Self-Directedness and high scores in Self-Transcendence.

We present results from a re-analysis of the Iowa family study of obsessive-compulsive disorder (OCD) that previously concluded the disorder was not familial. These conclusions were based on Diagnostic Interview Schedule results of first-degree relatives (FDRs) and not a best estimate diagnosis (BED). For the re-analysis we reviewed raw data on OCD and control probands and their FDRs. Relatives had been assessed through structured interviews, validated questionnaires, family history, and medical records in some cases. BEDs were assigned through a blind consensus procedure employing DSM-IV criteria. The data were analyzed using logistic regression with generalized estimating equations to account for within family correlations. BEDs were assigned to 32 OCD probands, 31 control probands, and 352 FDRs, including 249 FDRs who were interviewed directly and 103 FDRs who were unavailable or deceased. Lifetime prevalence of definite/probable OCD was significantly higher in the FDRs of OCD probands than controls (10.7% vs. 3.8%, OR=3.04, p=0.026). FDRs of OCD probands had significantly higher rates of depressive illness than relatives of controls. Depression of any type in relatives was predicted by the proband's depression history. We conclude that OCD is familial. The re-analysis highlights the importance of the BED procedure in family studies.

We report the treatment experience of 164 subjects with BPD who participated in a randomized clinical trial testing the Systems Training for Emotional Predictability and Problem Solving group treatment programme. Participation in psychotherapy, use of psychotropic medication, use of emergency services and hospitalization were carefully tracked. Nearly all (96%) subjects were prescribed psychotropic medication; 74% took antidepressants at baseline; the figures were 41% for anxiolytics, 39% for mood stabilizers and 32% for antipsychotics. Sixty-four percent reported taking ≥2 medications, and 39% took ≥3 medications. Most subjects (73%) participated in individual psychotherapy; 24% had been hospitalized at least once in the month prior to study entry. Importantly, medication usage at baseline was not associated with clinical severity. Medication usage declined during the 20-week clinical trial and 1-year follow-up. Few patients (6%) had ever received electroconvulsive therapy. In conclusion, data show that many persons with BPD are prescribed multiple medications and frequently participate in individual and other types of psychotherapy. Medication usage at baseline does not explain variation in clinical symptoms. Implications of the findings are discussed. Copyright © 2011 John Wiley & Sons, Ltd.

ObjectiveWe sought to determine attitudes toward patients with borderline personality disorder (BPD) among mental health clinicians at nine academic centers in the United States.MethodsA self-report questionnaire was distributed to 706 mental health clinicians, including psychiatrists, psychiatry residents, social workers, nurses, and psychologists.ResultsThe study showed that most clinicians consider BPD a valid diagnosis, although nearly half reported that they preferred to avoid these patients. The clinician's occupational subgroup was significantly related to attitude. Staff nurses had the lowest self-ratings on overall caring attitudes, while social workers had the highest. Social workers and psychiatrists had the highest ratings on treatment optimism. Social workers and psychologists were most optimistic about psychotherapy effectiveness, while psychiatrists were most optimistic about medication effectiveness. Staff nurses had the lowest self-ratings on empathy toward patients with BPD and treatment optimism.DiscussionNegative attitudes persist among clinicians toward BPD, but differ among occupational subgroups. Overall, caring attitudes, empathy, and treatment optimism were all higher among care providers who had cared for a greater number of BPD patients in the past 12 months.ConclusionThese findings hold important implications for clinician education and coordination of care for patients with BPD.

The authors report the results of a pilot project to introduce the STEPPS (systems training for emotional predictability and problem solving) treatment program for persons with borderline personality disorder (BPD) to the United Kingdom. STEPPS combines cognitive-behavioral principles and skills training with a systems component that includes family members and significant others. STEPPS was developed to supplement the patient’s ongoing treatment program (e.g. medication, individual therapy, case management) and boost its effectiveness, but not replace it. Thirty-eight subjects agreed to participate at six sites in West Sussex, England. A pre- and post-intervention comparison design was used, and over the 20 week program were found to have significant improvement in their mood, BPD-related symptoms (including affective, cognitive, and impulsive domains), and both negative and positive affectivity. Subjects reported high levels of satisfaction with the program. This study provides further evidence that STEPPS, a relatively brief fully manualized group treatment program, may be used in other countries and achieves high levels of acceptance from patients and therapists.

Few predictors of treatment outcome or early discontinuation have been identified in persons with borderline personality disorder (BPD).The aim of the study was to examine the relationship between baseline clinical variables and treatment response and early discontinuation in a randomized controlled trial of System Training for Emotional Predictability and Problem Solving, a new cognitive group treatment.Improvement was rated using the Zanarini Rating Scale for BPD, the Clinical Global Impression Scale, the Global Assessment Scale and the Beck Depression Inventory. Subjects were assessed during the 20 week trial and a 1-year follow-up.Higher baseline severity was associated with greater improvement in global functioning and BPD-related symptoms. Higher impulsivity was predictive of early discontinuation. Optimal improvement was associated with attendingor = 15 sessions.Subjects likely to improve have the more severe BPD symptoms at baseline, while high levels of impulsivity are associated with early discontinuation.

Borderline personality disorder (BPD) has been associated both with frontolimbic dysfunction and maladaptive personality traits such as impulsivity and neuroticism. The purpose of this study was to examine whether there are differences in predictive variance between neuropsychological variables and selected personality traits in persons with BPD. We compared persons with DSM-IV BPD (n = 25) to individuals without BPD or substance abuse (n = 20). All subjects completed a battery of neuropsychological tests, Cloninger's Temperament and Character Inventory, and the Barratt Impulsiveness Scale. BPD subjects had evidence of cognitive inhibition, and deficits in working memory, perseveration, and decision-making not accounted for by IQ differences between groups. In particular, Stroop Interference remained significant after controlling for IQ, depression and alcohol use (p = 0.043). They also had higher levels of impulsivity, novelty seeking and harm avoidance, but lower levels of self-directedness and cooperativeness than the comparison group. Logistic regression analyses indicated that both personality traits (Nagelkerke R2 = 0.74, Model χ2 = 36.21, p < 0.001) and neuropsychological tests (Nagelkerke R2 = 0. 47, Model χ2 = 19.22, p < 0.001) were significant predictors of BPD. However, neuropsychological tests did not add significant incremental variance over selected personality trait dimensions in predicting BPD (Block χ2 = 6.45, p = 0.168), whereas personality traits added significant incremental variance over neuropsychological tests in predicting BPD (Block χ2 = 3.44, p < 0.001). This study suggests that persons with BPD have impaired neuropsychological performance, but that impulsivity and other selected personality traits have a primary role in predicting BPD over and above neuropsychological test abnormalities. Copyright © 2009 John Wiley & Sons, Ltd.

Introduction:An uncontrolled pilot study of SystemsTraining for Emotional Predictability and Problem Solving (STEPPS) was conducted with incarcerated women offenders. STEPPS is a promising new cognitive-behavioral group treatment for persons with borderline personality disorder (BPD).Methods:Twelve women offenders withDiagnostic and Statistical Manual of Mental Disorders, Fourth EditionBPD were enrolled in the 20-week program at an Iowa prison. Efficacy assessments included the Borderline Evaluation of Severity overTime, the Positive and Negative Affectivity Scale, and the Beck Depression Inventory. Data were collected at baseline, and weeks 4, 8, 12, 16, and 20. A prison therapist was trained to deliver the STEPPS program.Results:The 12 volunteers had a mean age of 34.8±8.5 years. Two women discontinued early because they were released from prison; the others attended all sessions. The analysis showed significant improvements in BPD-related symptoms, negative affectivity, and depression. The Borderline Evaluation of Severity over Time total score was highly significant at week 20 (P=.009), indicating overall improvement in BPD-related symptoms. Effect sizes for the efficacy measures were moderate to large. The prison therapist showed excellent adherence to the model.Conclusion:This study demonstrated the successful implementation of the STEPPS program in a women's prison. Participants achieved “real-world” benefits, including a reduction in the negative thoughts and behaviors associated with BPD, negative affectivity, and depression. Implications of the findings are discussed.

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.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.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.STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

SUMMARY Systems Training for Emotional Predictability and Problem Solving, or STEPPS, a group treatment for outpatients with borderline personality disorder (BPD), is described. The 20-week program was developed to address the cognitive distortions and behavioral dyscontrol that occurs in borderline patients. STEPPS combines psychoeducation and skills training with a systems component, the latter involving significant others, health care professionals, and others with whom the patient regularly interacts. Data from the U.S. and The Netherlands have shown that the model is well accepted by patients and therapists, and is effective in relieving depression and other symptoms associated with the disorder.

Background The objective of the study was to test the association of age with symptom severity, frequency and pattern of psychiatric comorbidity, health care utilization and quality of life in subjects with borderline personality disorder (BPD). Methods The analysis is based on a sample of subjects with Diagnostic and Statistical Manual of Mental Disroders, Fourth Edition (DSM-IV) BPD (n = 163) recruited for participation in a clinical trial at an academic medical center. The subjects were assessed using structured and semi-structured instruments of known reliability. Results Tests of trend with age showed relationships with important variables assessing symptom severity, comorbidity, quality of life and health care utilization. As expected, younger subjects were less likely to be married, to be employed or to receive disability payments. The frequency of most lifetime comorbid Axis I disorders was not related to age, although posttraumatic stress disorder was more frequent in the 35- to 44-year age group, and younger patients were more likely to have comorbid histrionic and narcissistic personality disorders. Baseline severity variables were mostly unrelated to age, with the exception of impulsivity, which was more common in younger patients, as were acts of deliberate self-harm. As expected, older patients reported poorer quality of life in categories indicating worse health perception and greater pain levels, and tended to use more health care resources than younger patients. Conclusion Most characteristics of patients with BPD are unrelated to age, yet impulsivity and acts of deliberate self-harm were less frequent in older patients. Expected age-related changes, such as reports of worse physical health, greater pain levels and greater health care utilization, were observed in older subjects. Copyright © 2008 John Wiley & Sons, Ltd.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment for persons with borderline personality disorder (BPD). We describe results from two data sets on outcome in persons who participated in STEPPS with BPD alone or BPD plus antisocial personality disorder (ASPD). In Study 1, we examined the effect of comorbid ASPD on outcome in 65 persons with BPD who participated in a randomized controlled trial at an academic medical centre. In Study 2, we examined the effect of comorbid ASPD on outcome in 64 offenders with BPD who participated in STEPPS in correctional settings. All subjects were assessed for the presence of BPD and ASPD. In Study 1, subjects with ASPD experienced greater improvement in BPD symptoms, impulsiveness and global symptoms. In Study 2, offenders with ASPD experienced greater improvement in positive and negative behaviours and positive affectivity. We conclude that persons with BPD plus ASPD benefit from STEPPS in community and correctional settings. The findings suggest that persons with BPD plus ASPD show greater improvement in some domains than persons with BPD only. People with ASPD should not be automatically excluded from participation in the program. Copyright © 2015 John Wiley & Sons, Ltd.

Objective:To examine the presence of borderline personality disorder (BPD) traits in Gulf War veterans, and to assess psychiatric comorbidity, health status, healthcare utilization, and quality of life (QOL) along a continuum of BPD trait severity.Method:BPD and traits were evaluated using the Schedule for Non-Adaptive and Adaptive Personality in 576 veterans who were either deployed to the Persian Gulf (1990–1991) or were on active duty though not deployed to the Gulf. Demographic and military characteristics, personal and family history, psychiatric comorbidity, and QOL were also assessed.Results:One or more BPD traits were present in 247 subjects (43%), and BPD (≥5 traits) was identified in 15 subjects (3%).The number of traits was significantly associated with age and level of education. Lifetime psychiatric comorbidity was significantly associated with the number of BPD traits present, and level of functioning, health status, healthcare utilization, social functioning, self-injurious tendencies, and military/behavioral problems.Conclusion:BPD and traits identified in Gulf War veterans were associated with significant psychiatric morbidity, poorer QOL, and increased utilization of healthcare resources. Early recognition and treatment of veterans with BPD symptoms may be warranted to minimize the burden on the healthcare system.

Background Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a new cognitive group treatment for outpatients with borderline personality disorder. Methods The English and Dutch language literature was reviewed on the STEPPS program. Results STEPPS was introduced in The Netherlands in 1998 under the acronym VERS. Reasons for its rapid dissemination throughout Holland include a user-friendly manual, its 20-week duration, ability to maintain the patient's current treatment team, and ease of therapist training. Two pilot studies, one in the US and one in The Netherlands, suggest its efficacy. Randomized controlled trials are now underway. Conclusions STEPPS has become widespread in The Netherlands, and is now being modified for other settings, such as programs for adolescents.

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.

The authors describe a new cognitive-behavioral systems-based group treatment for outpatients diagnosed with borderline personality disorder (BPD). The program is identified by the acronym STEPPS, which stands for Systems Training for Emotional Predictability and Problem Solving. The STEPPS program was developed to address the cognitive distortions and behavioral dyscontrol typical of clients with BPD, and combines this with skills training and a systems component. The latter involves clients with BPD and those in their system including family members, significant others, and health care professionals. The program is fully manualized, and involves 20 two-hour weekly group meetings; specific goals (or lessons) are identified for each session. Preliminary data from the US and the Netherlands have shown that the group achieves high levels of acceptance from clients and therapists and that the model may be effective in helping to relieve the symptoms associated with BPD. Work is now underway to confirm the effectiveness of the model through a randomized controlled trial.

STEPPS (Systems Training for Emotional Predictability and Problem Solving) is a manualized, cognitive-behavioral, skills-based group treatment program originally developed in the USA for adults with borderline personality disorder (BPD) (Black, Blum, Pfohl, & St. John, 2004, 2012; Blum, Bartels, St. John, & Pfohl, 2002); the manual was also adapted for use in the UK (Blum, Bartels, St. John, & Pfohl, 2009), and the program is widely used in the Netherlands under the title VERS (Van Wel et al., 2006). The program is evidence based, as designated by the National Registry for Evidence-Based Practices (NREPP 2012). Although it was originally conceptualized as an outpatient program, STEPPS has been successfully adapted and implemented in a variety of settings, including inpatient units, partial hospital, day treatment programs, residential treatment facilities, substance abuse treatment, and correctional settings, including both male and female offenders in prisons and community corrections. In this chapter, an adaptation of STEPPS for adolescents in the UK will be described.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a manual-based group treatment of persons with borderline personality disorder (BPD). We report results from a study of offenders supervised by the Iowa Department of Corrections. Seventy-seven offenders participated in STEPPS groups. The offenders experienced clinically significant improvement in BPD-related symptoms (d = 1.30), mood, and negative affectivity. Suicidal behaviors and disciplinary infractions were reduced. Baseline severity was inversely associated with improvement. The offenders indicated satisfaction with STEPPS. We conclude that STEPPS can be successfully integrated into the care of offenders with BPD in prison and community corrections settings.

The tridimensional theory of personality posits that traits belonging to a personality spectrum called 'reward dependence' are determined in part by the neurotransmitter norepinephrine (NE). We hypothesized that urinary levels of the NE metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) would be significantly correlated to the reward dependence score on the Tridimensional Personality Questionnaire (TPQ). Twenty-seven never psychiatrically ill subjects collected urine for MHPG measurements and completed the TPQ. There was a significant correlation between the reward dependence score and the level of MHPG. MHPG levels was not associated with the other two personality dimensions, novelty seeking and harm avoidance. This preliminary study supports the hypothesis that reward-dependence traits are in part determined by NE.

The authors report on 60 persons with lifetime psychosexual dysfunction from a non-patient sample. The subjects were first-degree relatives of either healthy controls or patients with obsessive-compulsive disorder. The diagnosis of psychosexual dysfunction was based on Diagnostic Interview Schedule results. Of the 60 subjects, 34 (56.7%) were female; the mean (SD) age of subjects was 38.1 (14.6) years. Subjects with psychosexual dysfunction were significantly less likely than those without psychosexual dysfunction to be married. After correcting for marital status, there were few differences between groups. One of the few differences was that the mean personality disorder criteria endorsed (using the Structured Interview for DSM-HI Personality Disorders—SIDP) was significantly greater among relatives with psychosexual dysfunction (p >.03). Subjects with psychosexual dysfunction (mostly lack of interest) were more likely to endorse individual items from the SIDP and the Personality Diagnostic Questionnaire...

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.

This study reports on the demographics, phenomenology, and family history of 22 compulsive hair pullers. Subjects were recruited through a psychiatric outpatient clinic as well as newspaper advertisements. Subjects completed a semistructured interview focused on hair-pulling behavior and demographics, the Diagnostic Interview Schedule to assess major (Axis I) mental disorders, and the Structured Interview for DSM-III-R Personality Disorders to assess Axis II disorders. The typical subject was a 33-year-old woman who had completed 1 or more years of college and had been pulling her hair for 19 years. Nearly two-thirds met the criteria for a major mental disorder (particularly anxiety and mood disorders), and more than one-half met the criteria for a personality disorder. Nearly three-quarters of first-degree relatives were reported to have a psychiatric disorder, and about 5% were reported to be hair pullers.

The diagnostic overlap among the personality disorders is quite large. A central issue is to find a conceptual model that can account for this overlap. Lilienfeld, et al. argued that the use of the term “comorbldtty” suggests a disease model. However, a high degree of co-morbidity is not plausible in the context of a disease model. Instead, Lilienfeld et al. argued in favor of a prototype model. In this paper, we show that proto-typic cases of the personality disorders are very infrequent. If a patient meets most or all of the diagnostic criteria for any single personality disorder, then that patient is likely to meet numerous criteria for other personality disorders. The prototype model is no more consistent with the diagnostic overlap data than is the disease model.

OBJECTIVE The authors sought to determine the frequency of DSM-III personality disorders in subjects with obsessive-compulsive disorder, well comparison subjects, and their first-degree relatives. METHOD Thirty-two subjects with obsessive-compulsive disorder and 33 age-(within 5 years) and gender-matched well comparison subjects were assessed with the Structured Interview for DSM-III Personality Disorder and several self-report instruments. Their first-degree relatives were assessed in a blind manner with the same instruments. RESULTS Subjects with obsessive-compulsive disorder were more likely than well comparison subjects to have a personality disorder, but compulsive personality was not the most frequent. No significant differences were found in the prevalence of personality disorders among first-degree relatives, including compulsive personality, or in obsessional, hysterical, or oral character traits. CONCLUSIONS Personality disorders are highly prevalent among patients with obsessive-compulsive disorder, but the data do not support a relationship between obsessive-compulsive disorder and compulsive personality.

Sixty-nine depressed inpatients assessed for DSM-III personality disorders (PDs) were followed up after 4 years. Patients with unstable PDs (USPD; borderline, narcissistic, histrionic, and antisocial PDs) were compared with all other depressives. Considering patients of all ages, USPD was unrelated to course and weakly related to suicidal behavior. In post hoc analyses, patients were divided into “younger” (aged 18—25) and “older” (over 25). USPD but not other PDs predicted more episodes of depression, more manipulative suicidal behavior, and more medically serious suicide attempts among older depressives. USPD was unrelated to prognosis among younger depressives. This may be because many young USPDs will reach higher levels of adaptive functioning over several years, whereas USPDs still requiring hospitalization beyond their mid-20s tend to have more intractable character pathology with poorer long-term prognosis.

This study examined whether changes in diagnostic criteria from the DSM-III to the DSM-III-R for personality disorders (PDs) had the intended effects. Seventy-two subjects at the University of Iowa from three research studies and one clinical sample were administered two structured interviews (the Structured Interview for DSM-III Personality [SIDP] and the revised SIDP [SIDP-R]) to assess DSM-III and DSM-III-R criteria. Major changes in rates of diagnoses were observed between the DSM-III and DSM-III-R criteria with kappas for agreement ranging between −.025 and .571. As expected, the switch from monothetic to polythetic definitions had an effect on which patients were assigned a given diagnosis. However, not all of the other revisions associated with the DSM-III-R had the intended effects. For instance, the frequency of the diagnosis of schizoid PD did not increase, nor did the overlap between borderline and histrionic PDs decrease. In addition, there was an unintended increase in the rate of paranoid PD. An analysis of individual criteria showed how small, apparently minor changes in the wording of criteria can sometimes have major effects on which patients received a diagnosis of PD.

Obsessive-compulsive disorder (OCD) is a distressing and potentially disabling disorder characterized by intrusive obsessional thoughts and repetitive ritualistic behaviors. In recent years, OCD has been recognized as a relatively common condition that responds well to treatment, usually a combination of medication and behavioral therapy. Support groups, usually patient-generated, have become popular adjuncts to the treatment of a variety of conditions. Their applicability to OCD is explored in this report and a successful model developed by the authors is described. The model emphasizes patient education and emotional support. A similar group for family members is also described. Both groups have provided interdisciplinary training experiences for resident physicians in psychiatry, medical and nursing students, and social work practicum students.

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.

TheDiagnostic and StatisticalManual ofMental Disorders. Third Edition, Revised (DSM-III-R) criteria for obsessivecompulsive personality disorder (OCPD) represent an attempt to capture a historical concept whose im plications and validity are largely unknown. The modern roots of OCPD go back at least as far as Freud, who described the anal character type. In his classic 1908 paper, Freud outlined the anal character as arising from a defense against anal eroticism and described such individuals as "orderly, parsimonious and obstinate. . Orderly covers the notion of bodily cleanliness, as well as conscientiousness in carrying out small duties and trustworthiness. . . . Parsimony may [include] . . . avarice; and obstina cy can go over into defiance, to which rage and revengefulness are easily joined" (Freud, 1908/1959, p. 169). In 1921 Abraham developed this concept further with a rich description of character traits that have been concisely summarized in a review by Oldham and Frosch (1988)

This article reports a study that explored the retirement experiences of a national sample of retired social work educators. A total of 267 educators responded to a mailed questionnaire that addressed five areas: (1) general characteristics of the subjects, (2) their preretirement experiences, (3) their postretirement experiences, (4) current social and health status, and (5) their perspectives on changes in social work education and practice. The sample was found to be relatively young, healthy, moderately professionally active, financially secure, and relatively satisfied with their retirement experiences. Critical differences were found on the five variables by gender, terminal degree, and institutional affiliation.

Objective: The objective of the study was to compare symptom severity, frequency, and pattern of psychiatric comorbidity, quality of life, and health care utilization in men and women with borderline personality disorder (BPD). Methods: The analysis is based on a sample of 163 subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BPD recruited for participation in a clinical trial at an academic medical center. Subjects were administered structured interviews and questionnaires of known reliability. Results: Men (n = 25) and women (n = 138) with BPD were compared across multiple domains. Men were significantly older than women (34.5 vs 30.4 years), but subjects were otherwise similar in their demographic characteristics. Overall syndrome severity and frequency of past suicide attempts and self-harm behaviors were also similar. Women were more likely than men to have an anxiety disorder (particularly generalized anxiety disorder), somatoform disorders, and histrionic personality disorder. Antisocial personality disorder was more common in men. Women had higher dimensional ratings of depression, anxiety, obsessive-compulsiveness, work dysfunction, and negative affectivity; they were also more likely to endorse the “paranoia/dissociation” BPD criterion. On the Short Form-36 Health Survey, women reported significantly worse emotional role, social role, and mental health functioning than men. Contrary to expectation, there were no significant cross sex differences in the use of health care resources. Conclusion: Men and women with BPD show important differences in their pattern of psychiatric comorbidity, dimensional symptom ratings, and in quality of life variables. Women have more negative views of themselves, and worse overall emotional and social role functioning. Implications for clinicians and researchers are discussed.

Background: The objective of the study was to estimate the rate of borderline personality disorder (BPD) in male and female offenders newly committed to the Iowa Department of Corrections. We also compared clinical and demographic characteristics of offenders with and without BPD. Methods: A random sample of 220 offenders entering Iowa's prison system were evaluated by using a version of the Mini International Neuropsychiatric Interview, the BPD module of the Structured Interview for DSM-IV Personality Disorders, the Medical Outcome Survey Short Form-36 Health Survey, and the Level of Service Inventory-Revised. Results: Borderline personality disorder was present in 65 (29.5%) subjects, although 93.2% had at least one Diagnostic and Statistical Manual of Mental Disorders-IV BPD trait. The percentage of women meeting criteria for BPD was more than twice that for men. Subjects with BPD were more likely than those without to be married, employed, and to have a high suicide risk score. Offenders with BPD were more likely than others to report prior mental health treatment, and to have reported high levels of interference from their mental disorder. Offenders with BPD had worse quality of life than offenders without BPD as assessed with the Medical Outcome Survey Short Form 36 Health Survey, and higher rates of mood, anxiety, psychotic, and eating disorders; antisocial personality disorder; and attention deficit hyperactivity disorder. Borderline personality disorder was also associated with higher Level of Service Inventory-Revised total scores, which indicates their having a greater risk for recidivism than nonborderline offenders. These relationships were observed after adjusting for sex, age, race/ethnicity, and presence of antisocial personality disorder. Conclusion: Borderline personality disorder is relatively common among both male and female offenders in prison, and is associated with substantial psychologic stress and impaired quality of life. Early recognition and treatment of BPD in prisons may be warranted.

Objective: The authors studied factors associated with short-term treatment response in 38 nondepressed subjects with DSM-III-R obsessive-compulsive disorder (OCD), Method: The subjects completed 12 weeks of treatment with paroxetine (N= 20), placebo (N = 8), or cognitive-behavioral therapy (N= 10). Clinician and self-rated measures were gathered at baseline, during treatment, and after treatment. Results: Seventeen (45%) subjects had much or very much improvement and achieved at least a 40% decrease in their total Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. Responders had lower obsessive-compulsive scores on the Symptom Checklist 90-Revised, had a lower checking score on the Maudsley Obsessive-Compulsive Inventory, were less likely to have had prior drug therapy, and in general suffered more obsessive-compulsive symptoms. They were significantly less likely to have hoarding obsessions and corresponding compulsions. The latter finding was confirmed using multiple regression analysis. Conclusion: Hoarding is an important symptom that predicts poor treatment response in patients with OCD.

The authors report findings from a blind, controlled study of obsessive-compulsive disorder (OCD). Prevalence rates of generalized anxiety disorder (GAD) and major depressive disorder (MDD) were compared among first-degree relatives of probands with OCD and co-morbid GAD or MDD, respectively. Rates of MDD were not increased in relatives of probands with OCD and MDD; neither were rates of GAD increased in relatives of probands with OCD and GAD, although rates of GAD were increased among relatives of probands with OCD compared to relatives of healthy controls. The authors explore the implications of the findings.

The lifetime prevalence of eating disorders and pathologic gambling was assessed in first-degree relatives of subjects with obsessive-compulsive disorder (OCD) and well controls. There were no significant differences between the groups. The authors conclude that eating disorder and pathologic gambling have no familial relationship to OCD.

The authors systematically interviewed 88 bariatric clinic patients presenting for vertical banded gastroplasty. The typical subject was middle-aged, female and of low socioeconomic status as indicated by his or her method of payment. Morbidly obese subjects were more likely than a comparison group to have first-degree relatives with a history of depression, bipolar disorder, antisocial personality, and other psychiatric disorders. These data indicate that relatives of morbidly obese subjects are frequently emotionally disturbed. Reasons for the findings are discussed.

In psychiatric research, measurement of biological substances is often made in control groups. Controls are given the same biological tests as are the psychiatric patients to determine whether the patiems have an gonormality of the tested substance. Oftentimes, differences in biological measurements between ill subjects and healthy con~'ols ~'e not ~eat, ~ d ~.,er!ap of v~ues usually exists. In trying to ascertain whether a certain biological variable is associated with a particular disease condition, it is important that the control grouF be carefully screened. In one study, an advertisement was used to golicit pgychiatrically healthy subjects (Coryell and Zim~erman 1987). Telephone screening of the 128 people who responded to the ad eliminated 59 individuals with a history of psychiatric problems.In spite of tiffs, 25 (36%) of the remaining 69 subjects gave a history of psychiatric problems when interviewed with a detailed diagnostic questionnaire. Even for carefully screened control subjects there is still the issue of w~ether a positive fan~., ~!y histo~ of psychiatric illness m i ~ influence yalues for certain biological substances. Sedvall et al. (1980) r epor~ ~at control sub]ect~ wi~, deviant cerebrospinal fluid (CSF) neurotrans

We administered the Tridimensional Personality Questionaire (TPQ) to a sample of 25 individuals with obsessive-compulsive disorder (OCD) and 35 normal controls. As predicted, OCD cases scored much higher on the harm avoidance dimension than normal controls. Findings for the novelty seeking and reward dependence dimensions were less dramatic, although compatible with the underlying theory. Despite a theoretical link between the harm avoidance dimension and serotonin-mediated neuropathwaysm we failed to find an association between this dimension and platelet imipramine binding in either OCD cases or controls.

First-degree relatives of probands with obsessive-compulsive disorder (OCD) (n = 32) and psychiatrically normal controls (n = 33) were blindly interviewed with the use of the Diagnostic Interview Schedule. The morbidity risk for anxiety disorders was increased among the relatives of obsessional subjects compared with that for the relatives of controls, but the risk for OCD was not. Risk for a more broadly defined OCD (including relatives with obsessions and compulsions not meeting criteria for OCD) was increased among the parents of obsessional subjects but not among the parents of controls (16% vs 3%). The findings suggest that an anxiety disorder diathesis is transmitted in families with OCD, but that its expression within these families is variable. The findings also support the current practice of classifying OCD as an anxiety disorder.

Knowledge of the age cohort factor is valuable to the activities programmer in program planning with the elderly. The authors discuss the cultural paradigm shift which has occurred in the twentieth century. By comparing the socializing outcomes of the elderly industrial age cohort with the postindustrial age cohort, a series of principles for activities programming and specific sets of activities based on these principles are established.