The addition of STEPPS in the treatment of patients with bipolar disorder and comorbid borderline personality features: a protocol for a randomized controlled trial

Abstract

BackgroundBipolar disorder (BD) and borderline personality disorder (BPD) both are severe and chronic psychiatric disorders. Both disorders have overlapping symptoms, and current research shows that the presence of a BPD has an adverse effect on the course of BD. The limited research available shows an unfavorable illness course, a worse prognosis and response to medication, longer treatment duration, more frequent psychiatric admissions, higher drop-out, increased risk of substance abuse, increased risk of suicide, and more impairment of social and occupational functioning. However, there is no research available on the effect of specific psychotherapeutic treatment for this patients.Methods/DesignThis paper presents the protocol of a RCT to investigate the presence of borderline personality features in patients treated for BD (study part 1) and the effectiveness of STEPPS (Systems Training for Emotional Predictability and Problem Solving) added to treatment as usual (TAU) for BD compared to TAU in patients with BD and comorbid borderline personality features (study part 2). STEPPS is a validated and effective intervention for BPD. The study population consists of patients treated for BD at specialized outpatient clinics for BD in the Netherlands. At first the prevalence of comorbid borderline personality features in outpatients with BD is investigated. Inclusion criteria for study part 2 is defined as having three or more of the DSM-IV-TR diagnostic criteria of BPD, including impulsivity and anger bursts. Primary outcomes will be the frequency and severity of manic and depressive recurrences as well as severity, course and burden of borderline personality features. Secondary outcomes will be quality of life, utilizing mental healthcare and psychopathologic symptoms not primarily related to BD or BPD. Assessment will be at baseline, at the end of the intervention, and at 12 and 18 months follow-up.DiscussionThis will be the first randomized controlled trial of a specific intervention in patients with BD and comorbid BPD or borderline personality features. There are no recommendations in the guideline of treatment of bipolar disorders for patients with this complex comorbidity. We expect that a combined treatment aimed at mood disorder and emotion regulation will improve treatment outcomes for these patients.

Exploring the Effectiveness of Dialectical Behavior Therapy Versus Systems Training for Emotional Predictability and Problem Solving in a Sample of Patients With Borderline Personality Disorder

“…STEPPS has also been studied in forensic groups, such as prisoners with BPD, and findings showed that STEPPS resulted in reductions in BPD severity with a large effect size from baseline to the end of treatment (Black, Blum, McCormick, & Allen, 2013). STEPPS has been tested in the treatment of bipolar disorder and comorbid personality features (Reimann et al, 2014).…”

Bipolar Disorder and Comorbid Borderline Personality Disorder: Patient Characteristics and Outcomes in US Hospitals

“…Riemann et al reported that bipolar disorder patients with comorbid BPD are more likely to be hospitalized and have an increased risk of substance abuse [8]. As per the National Comorbidity Survey Replication, the prevalence of alcohol abuse and drug abuse in bipolar patients is 39.1% and 28.8% respectively [3].…”

“…The presence of comorbid BPD had a negative impact on the clinical course of bipolar disorder as the patients had an unfavorable illness trajectory, higher likelihood of hospitalization, longer treatment duration and worse response to treatment [7]. Riemann et al concluded from a study in a multicenter outpatient that bipolar patients with BPD had a higher treatment drop-out rate, increased risk of substance abuse, and greater impairment of social and occupational functioning [8]. As bipolar disorder and BPD are each risk factors for suicidal behavior, patients with co-occurring bipolar disorder and BPD present with a higher suicide risk [9].…”

“…The quality of life and disease outcomes in bipolar patients are adversely affected by the presence of comorbid BPD [7,8]. Given the increased risk of psychiatric hospitalizations and suicide [9], the assessment and treatment of comorbid BPD in bipolar patients is crucial for improved patient outcomes and reducing suicide risk.…”

Emotional dysregulation in those with bipolar disorder, borderline personality disorder and their comorbid expression

“…One recent treatment protocol involved an RCT of a psychotherapeutic treatment versus treatment as usual for bipolar disorder (Riemann et al, 2014), andMcDermid andMcDermid (2016), argued comorbid BP/BPD resulted in 'emotional frailty' and diminished 'complexity' -and recommended developing sufficient complexity through targeting internal coping strategies while utilising external psychological supports to develop optimal emotional reactivity. Parker (2015) has advocated a two-tier approach to treatment for those with comorbid BP/BPD -the first step involving treating the bipolar illness predominantly with a mood stabilising agent and then addressing the BPD with a psychotherapy.…”