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Stepped Care: An Alternative to Routine Extended Treatment for Patients With Borderline Personality Disorder
Joel Paris, M.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200451
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Dr. Paris is affiliated with the Institute of Community and Family Psychiatry, Jewish General Hospital, and the Department of Psychiatry, McGill University, 4333 cote Ste. Catherine, Montreal, Quebec H3T1E4, Canada (e-mail: joel.paris@mcgill.ca).

Copyright © 2013 by the American Psychiatric Association


This review examined evidence supporting stepped care for borderline personality disorder as an alternative to routine extended treatment. Empirical studies have shown that patients with borderline personality disorder have a heterogeneous course, but symptomatic improvement can sometimes be relatively rapid. Currently, there is no evidence that any long-term treatment is superior to briefer interventions for borderline personality disorder. Long-term therapy may not be necessary for all patients, and its routine use leads to access problems. A stepped-care model, similar to models applied to other severe mental disorders, might provide a better use of resources. Stepped care can be used to limit the use of expensive programs and reduce waiting lists. Not all patients with borderline personality disorder can be treated briefly, but a stepped-care model allows those with less severe symptoms to be managed with fewer resources, freeing up more time and personnel for the treatment of those who need treatment the most.

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Paris  J:  The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category.  Journal of Personality Disorders 21:457–473, 2007
[CrossRef] | [PubMed]
Zanarini  MC;  Frankenburg  FR;  Reich  DB  et al:  Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study.  American Journal of Psychiatry 169:476–483, 2012
[CrossRef] | [PubMed]
Gunderson  JG;  Stout  RL;  McGlashan  TH  et al:  Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.  Archives of General Psychiatry 68:827–837, 2011
[CrossRef] | [PubMed]
Paris  J:  Personality Disorders Over Time .  Washington, DC,  American Psychiatric Publishing, 2003
Schwartzbaum  J;  Ahlbom  A;  Feychting  M:  Berkson’s bias reviewed.  European Journal of Epidemiology 18:1109–1112, 2003
[CrossRef] | [PubMed]
Zanarini  MC:  Psychotherapy of borderline personality disorder.  Acta Psychiatrica Scandinavica 120:373–377, 2009
[CrossRef] | [PubMed]
Mackenzie R: Time-limited psychotherapies: an overview; in American Psychiatric Review of Psychiatry. Edited by Dickstein L, Riba M, Oldham JM. Washington, DC, American Psychiatric Press, 1996
Stanley  B;  Brodsky  B;  Nelson  J  et al:  Brief dialectical behavior therapy (DBT-B) for suicidal behavior and non-suicidal self-injury.  Archives of Suicide Research 11:337–341, 2007
[CrossRef] | [PubMed]
Davidson  KM;  Tyrer  P;  Norrie  J  et al:  Cognitive therapy v usual treatment for borderline personality disorder: prospective 6-year follow-up.  British Journal of Psychiatry 197:456–462, 2010
[CrossRef] | [PubMed]
Blum  N;  St John  D;  Pfohl  B  et al:  Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up.  American Journal of Psychiatry 165:468–478, 2008
[CrossRef] | [PubMed]
Gunderson  JG:  Borderline personality disorder: ontogeny of a diagnosis.  American Journal of Psychiatry 166:530–539, 2009
[CrossRef] | [PubMed]
Linehan  MM:  Dialectical Behavior Therapy for Borderline Personality Disorder .  New York,  Guilford, 1993
McMain  SF;  Guimond  T;  Streiner  DL  et al:  Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up.  American Journal of Psychiatry 169:650–661, 2012
[CrossRef] | [PubMed]
Bateman  A;  Fonagy  P:  Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder.  American Journal of Psychiatry 166:1355–1364, 2009
[CrossRef] | [PubMed]
Bateman  A;  Fonagy  P:  Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment .  Oxford, United Kingdom,  Oxford University Press, 2004
Cook  JM;  Biyanova  T;  Elhai  J  et al:  What do psychotherapists really do in practice? An Internet study of over 2,000 practitioners.  Psychotherapy 47:260–267, 2010
[CrossRef] | [PubMed]
Kopta  SM;  Howard  KI;  Lowry  JL  et al:  Patterns of symptomatic recovery in psychotherapy.  Journal of Consulting and Clinical Psychology 62:1009–1016, 1994
[CrossRef] | [PubMed]
Leichsenring  F;  Rabung  S:  Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis.  British Journal of Psychiatry 199:15–22, 2011
[CrossRef] | [PubMed]
Davison  GC:  Stepped care: doing more with less? Journal of Consulting and Clinical Psychology 68:580–585, 2000
[CrossRef] | [PubMed]
Richards  DA:  Stepped care: a method to deliver increased access to psychological therapies.  Canadian Journal of Psychiatry 57:210–215, 2012
Zatzick  D;  Jurkovich  G;  Rivara  FP  et al:  A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors.  Annals of Surgery 257:390–399, 2013
[CrossRef] | [PubMed]
Lenzenweger  MF;  Lane  MC;  Loranger  AW  et al:  DSM-IV personality disorders in the National Comorbidity Survey Replication.  Biological Psychiatry 62:553–564, 2007
[CrossRef] | [PubMed]
Paris  J:  Intermittent psychotherapy: an alternative to continuous long-term treatment for patients with personality disorders.  Journal of Psychiatric Practice 13:153–158, 2007
[CrossRef] | [PubMed]
Prochaska  JO:  Strong and weak principles for progressing from precontemplation to action on the basis of twelve problem behaviors.  Health Psychology 13:47–51, 1994
[CrossRef] | [PubMed]
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