CPCP: Borderline Personality Disorder and Chronic Pain Management in Primary Care

Dr. Alka Walter MBBS

Dr. Alka Walter MBBS

So today’s Clinical Problems in Consultation Psychiatry (CPCP) presentation was absolutely spot-on and right up the alley for primary care clinicians and consultation psychiatrists in the general hospital. Dr. Alka Walter, MBBS, is a first year resident in Family Medicine rotating through the General Hospital Psychiatry Service and did an outstanding job of outlining the major issues.

Dr. Walter’s CPCP is relevant to her practice as well as to that of psychiatrists and it dovetails nicely with a recent Grand Rounds presentation about Borderline Personality Disorder with respect to an important treatment intervention called Systems Training for Emotional Predictability and Problem Solving (STEPPS). It’s one of several evidence-based treatments which include:

  • Cognitive Behavioral Therapy
  • Dialectical Behavior Therapy
  • Mentalization Based Therapy
  • Transference Focused Psychotherapy

Broadly speaking, Borderline Personality Disorder is a pervasive pattern of unstable interpersonal relationships (“I hate you, then I love you”), unstable self-image, unstable moods, and marked impulsivity.

According to the Grand Rounds presenters, research so far doesn’t tell us specifically which treatment works best for a particular patient. Treatment delivery mainly is driven by what’s accessible, practical for a facility to implement, and cost-effective. It’s important to have effective psychotherapy methods for treatment because the response to medications is non-specific, often there is modest improvement, and there may be exquisite sensitivity to side effects. The main features of STEPPS are that it:

  • Focuses on the present
  • Helps patients learn to manage their disorder by moving away from victimhood
  • Fosters lowering expectations that other people or things will rescue them
  • Teaches skills to others in their system, e.g., friends, significant others, individual therapists
  • It’s very acceptable to patients and therapists

Typically STEPPS has three main goals, which is to raise awareness of the illness and often reframe it as “Emotional Intensity Disorder” which is a term more in line with one’s experience of the illness; and two skills-building components, one for emotion management and one for behavior management.

A practical focus is helping patients learn how to recognize certain biases or maladaptive cognitive filters they may launch when under stress, such as vulnerability to harm and illness and abandonment among others, which are in play in primary care clinics in just the situations that Dr. Walter describes.

 References and Web Resources

Blum, N., LISW, and B. Pfohl, M.D. (2014). STEPPing Up to the Challenge of Borderline Personality Disorder. http://steppsforbpd.com/

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.




  1. Jim,

    Don’t forget Gunderson’s GPM model:


    Most psychiatrists are surprised to learn that office based GPM done by a psychiatrist has outcomes that are comparable to DBT.


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