Shame as a prospective predictor of self-inflicted injury in borderline personality disorder: a multi-modal analysis

Two Sides of the Same Coin in Female Borderline Personality Disorder: Self-Reported Guilt and Shame and Their Neurofunctional Correlates

OBJECTIVE

Patients with borderline personality disorder (BPD) report to be especially prone to social emotions like shame and guilt. At the same time, these emotions seem to play an important role in BPD pathology. The present study aimed to deepen the knowledge about the processes behind shame and guilt in patients with BPD.

METHODS

Twenty patients with BPD and twenty healthy controls (HCs) took part in an experiment that induced shame and guilt by imagining scenarios during scanning using functional brain imaging. Participants also filled out self-report questionnaires and took part in diagnostic interviews.

RESULTS

BPD patients reported more proneness to guilt but not to shame than the HCs. There was no difference in the self-reported intensity rating of experimentally induced emotions between the groups. Between-group contrast of neural signals in the shame condition revealed a stronger activation of cingulate and fusiform gyrus for the BPD patients compared to the controls, and a more pronounced activation in the lingual gyrus and cuneus for the HCs. In the guilt condition, activation in the caudate nucleus, the fusiform gyrus, and the posterior cingulate cortex was stronger in BPD patients, while HC showed stronger activations in cuneus, lingual gyrus, and fronto-temporal regions.

CONCLUSIONS

Differences in the neuro-functional processes between BPD patients and HC were found, even though the two groups did not differ in their self-report of subjective proneness to guilt and emotional intensity of shame and guilt during the experiment. While the HCs may be engaged more by the emotional scenarios themselves, the BPD patients may be more occupied with cognitive regulatory and self-referential processing.

Shame, suicidal ideation, and urges for non-suicidal self-injury among individuals with borderline personality disorder receiving dialectical behavior therapy: The mediating role of anger

INTRODUCTION

Borderline personality disorder (BPD) is a disorder of pervasive emotion dysregulation associated with high rates of self-injurious thoughts and behaviors (SITB). Understanding specific emotion states in relation to SITB is important for effective intervention.

METHODS

The current study examined whether, and how, the specific emotion of shame contributes to suicide ideation and urges to engage in non-suicidal self-injury (NSSI) both directly, and indirectly via anger, among individuals with BPD. Participants (N = 100) were enrolled in a 6-month comprehensive dialectical behavior therapy (DBT) program and provided daily ratings of shame, anger, suicide ideation, and urges for NSSI.

RESULTS

We found that higher daily ratings of shame and anger were directly associated with higher same-day ratings of both suicidal ideation and urges for NSSI. Furthermore, anger partially mediated the relationships between shame and both suicidal ideation and urges for NSSI.

CONCLUSION

These findings highlight shame and anger as potential antecedents of SITB among individuals with BPD. Clinical approaches, such as DBT, that include personalized, ongoing, clinical assessment of these specific affective states may be particularly important for treatment of SITB.

Associations between humiliation, shame, self-harm and suicidality among adolescents and young adults: A systematic review

BACKGROUND

Suicide is the second leading cause of death among young people worldwide. Research indicates that negative social contexts involving familial and peer relationships have far-reaching influences on levels of suicidality in later life. While previous systematic reviews have focused on evaluating associations between negative life events such as abuse and bullying in childhood and subsequent suicidality, this systematic review examines the prevalence of, and association between the processes of humiliation and shame in later self-harm, suicidal ideation, and suicide among adolescents and young adults.

METHODS

A systematic literature search of databases including MEDLINE, Web of Science Core Collection, CINAHL, PsycINFO, and Embase was conducted to identify potential studies. ProQuest was searched to identify relevant grey literature research. A combination of MESH terms and keywords was used. All original quantitative studies published in English that examined the prevalence, or association between humiliation or shame and suicidal behaviours and/or death by suicide were included. Studies were assessed for methodological quality using Joanna Briggs Institute critical appraisal tools. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022289843].

RESULTS

Narrative synthesis was performed. A total of 33 studies reporting the prevalence of, or association between humiliation (n = 10) or shame (n = 23) and suicidal thoughts/behaviours were included. The prevalence of humiliation among those with any suicidality ranged from 18% to 28.1%, excluding an outlier (67.1%), with two studies presenting a significant association between humiliation and self-harm in their fully adjusted analyses. The studies that outlined humiliation and suicidal thinking (intent/suicide plan) had no association after adjustment for confounders. For shame, half of the studies found an association in adjusted models (n = 10), and this was evident for both suicidal ideation and self-harm.

CONCLUSION

To our knowledge, this is the first study to attempt a systematic review on this topic. The dearth of research in this field of enquiry is reflective of unique challenges associated with assessments of humiliation and shame in various clinical settings amongst adolescent and young adult populations. Nonetheless, given the importance and relevance of the psychological imprint of humiliation in youth morbidity and mortality in the field of mental health, it is timely to attempt such a systematic review. In light of the associated role of humiliation and shame in self-harm and suicidality among young people, we recommend that these processes need to be explored further via prospective studies and assessed as part of a comprehensive bio-psycho-social assessment when focusing on life stressors for adolescent and young adults presenting with suicidality to emergency departments and mental health services.

The Clinical Interview for Borderline Personality Disorder for Adolescents (CI-BOR-A): Development, acceptability and expert panel evaluation

Borderline personality disorder (BPD) is a severe mental disorder with marked impulsivity, instability, emotional dysregulation and self-harm. These features tend to develop over time and can be identified in adolescence. Early diagnosis is the first step to prevent the development of these features to a personality disorder. The purpose of this study was to develop the Clinical Interview for BPD for Adolescents (CI-BOR-A), a new instrument based on a sound clinical interview for BPD in youth (CI-BPD). We tested its acceptability with 43 adolescents and its content validity with the quantitative and qualitative evaluation of 23 experts in mental health. The CI-BOR-A is a hybrid semi-structured interview that considers both categorical and dimensional approaches of personality disorders of DSM-5-TR, including 16 items, decision tables for diagnosis, and an appendix to explore self-harm history further. Adolescents accepted the interview, and none refused to complete the assessment. The expert panel considered the interview relevant, clear, accurate and complete. Important feedback was provided in terms of structure and content to improve the CI-BOR-A quality. In general, the CI-BOR-A is a rigorous interview to assess BPD in adolescents and adds an important contribution to early detection in clinical and community settings.

Social stressors, emotional responses, and NSSI urges and behaviors in daily life

BACKGROUND

The defective self model of nonsuicidal self-injury (NSSI) theorizes that individuals who are highly self-critical are more likely to choose NSSI to regulate emotions. This model indirectly suggests that individuals who engage in NSSI may experience more self-conscious emotions in response to negative social feedback, increasing risk for near-term NSSI. This study examined (1) whether individuals with a history of NSSI (vs. without) display greater self-conscious and negative emotional reactions to daily social stressors, and more problematic features of these daily social stressors, and (2) whether greater-than-usual negative emotional reactions and social stressor features predict NSSI urges and behaviors in daily life.

METHODS

Participants were 134 female college students with recent, recurrent NSSI (n = 77) or no NSSI history (n = 57). Participants completed baseline measures of socioemotional functioning and a two-week daily diary protocol.

RESULTS

The NSSI (vs. no NSSI) group reported significantly greater self-conscious and negative emotional reactions to daily social stressors, and social stressors characterized by greater dysfunction. In the NSSI group, experiencing social stressors characterized by greater distress than one's average during the daily diary period was associated with same-day NSSI urges and behavior, greater confusion than one's average predicted same-day NSSI urges, and greater conflict than one's average predicted same-day NSSI behavior. Greater self-conscious and negative emotional reactions to these stressors than one's average predicted same-day NSSI urges and behavior.

LIMITATIONS

Limitations include reliance on self-report, a once-daily assessment, and lack of generalizability to other samples.

CONCLUSIONS

Interpersonal conflict and increased self-conscious emotions pose vulnerability for NSSI. Prevention and intervention efforts would benefit from including a focus on interpersonal functioning.

A scoping review of psychosocial interventions to reduce internalised shame

Internalised shame has been linked to psychopathology and consistently identified as a predictor of poor treatment outcomes and premature therapy termination. We conducted a scoping review of therapist-delivered psychosocial interventions to reduce internalised shame to learn how to improve outcomes for individuals experiencing shame.

Six bibliographical databases were searched for studies measuring internalised shame pre- and post-treatment. We screened 6846 abstracts; 42 full-text manuscripts were retrieved, with 16 studies meeting the inclusion criteria. Of these, 10 studies examined between- and within-subject effects, and 6 studies exclusively examined within-subject effects.

Twelve of the sixteen included studies reported small to moderate within-group reductions in internalised shame. Between group analyses showed that shame interventions may be more effective than no treatment or treatment as usual, but not more effective than an active comparator.

Successful treatments often involved psychoeducation, experiential exercises, and techniques to increase social support and emotional expression; however, study quality was weak to moderate and the importance of each of these techniques for reducing internalised shame was not determined.

Associations between humiliation, shame, self-harm and suicidal behaviours among adolescents and young adults: A systematic review protocol

BACKGROUND

Suicide is the second leading cause of death among young people worldwide and remains a major public health concern. Research indicates that negative social contexts involving familial and peer relationships, have far-reaching influences on levels of suicidal behaviours in later life. Previous systematic reviews have focused on evaluating associations between negative life events such as abuse and bullying in childhood and subsequent self-harm or suicidality. However, the association between adolescent experiences of humiliation and shame, and subsequent self-harm or suicidal behaviour among children and young adults has not been well examined. As such, this systematic review is conducted to examine the prevalence and association between humiliation and shame and self-harm, suicidal ideation, and death by suicide among adolescents and young adults.

METHODS

A systematic literature search in extant electronic databases including; MEDLINE, Web of Science Core Collection, CINAHL, PsycINFO, and Embase will be conducted to identify potential studies. Google Scholar, and the reference list of the retrieved articles and/or previous systematic reviews in this area, will also be scanned to identify further potential studies. ProQuest will be searched to identify relevant studies available within grey literature. There are no restrictions on the date of publications. Based on our initial review, the following terms were identified: Population: Adolescent (MESH), young adult (MESH), teen, teenage. Exposure: Humiliation, degradation, shame (MESH) or embarrassment (MESH), harassment victimisation, abasement. Outcome: Self-injurious behaviour (MESH), suicide (MESH), suicide attempted (MESH), suicide completed (MESH), self-harm, intentional self-injury, deliberate self-harm, overdose, deliberate self-poisoning, non-suicidal self-injury, self-mutilation, suicidal thought, suicidal ideation, suicidal intent, suicide. At least one term from each category will be used for conducting the literature search. All original quantitative studies published in the English language which examined the prevalence or association between humiliation or shame and self-harm and/or suicidal ideation and/or completed suicide will be included. The studies will be assessed for methodological quality using the Joanna Briggs Institute critical appraisal tools. Narrative synthesis will be performed for all of the studies. If the studies are sufficiently homogenous, the results will be pooled for a meta-analysis. This systematic review protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) guidelines. The protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022289843].

DISCUSSION

This is the first review to synthesise evidence on the prevalence of, and associations between the experiences of humiliation and shame and subsequent self-harm and/or suicidal behaviours among adolescents and young adults. As there is growing evidence on increased self-harm among this age group, it is important to identify population-specific risk factors for self-harm and suicidality which will have significance in formulating tailored and effective treatment and therapeutic services for adolescents and young adults.

A mixed methods examination of emotional expression and its impact on emotion regulation effectiveness in borderline personality disorder

BACKGROUND AND OBJECTIVES

Emotional expression (i.e., identifying and labeling emotion using specific words), is theorized to reduce negative emotion and facilitate emotion regulation. However, it remains unclear how individuals with borderline personality disorder express emotion, and whether this influences their emotion regulation. This study examined whether: 1) emotional expression in borderline personality disorder differed from healthy controls based on word valence, emotionality, and vocabulary; and 2) whether such characteristics predict emotion regulation effectiveness across self-reported and physiological emotion domains differentially across these groups.

METHODS

Individuals with borderline personality disorder (n = 29) and age and sex-matched healthy controls (n = 30) listened to an evocative story, expressed emotion, and regulated emotion by applying Mindfulness or Cognitive Reappraisal. Emotion regulation was measured by changes in self-report, parasympathetic, and sympathetic emotion, while implementing the emotion regulation strategies. The words used to express emotion were coded based on valence, emotionality, and depth of vocabulary.

RESULTS

Generalized estimating equations revealed no differences between groups in valence, emotionality, and vocabulary. Additionally, using a larger emotional vocabulary predicted more effective sympathetic emotion regulation, and using more negatively valenced words predicted more effective parasympathetic emotion regulation across groups.

LIMITATIONS

Among other things, this study is limited by its predominantly female sample, and that it does not determine whether valence, emotionality, or vocabulary independently predict emotional expression effectiveness.

CONCLUSIONS

Emotional expression may not be deficient in borderline personality disorder across the indices studied. Using more negative words and broadening vocabulary while expressing emotion may offer emotion regulation benefits.

Autonomic factors do not underlie the elevated self-disgust levels in Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) is manifested along with non-motor symptoms such as impairments in basic emotion regulation, recognition and expression. Yet, self-conscious emotion (SCEs) such as self-disgust, guilt and shame are under-investigated. Our previous research indicated that Parkinson patients have elevated levels of self-reported and induced self-disgust. However, the cause of that elevation-whether lower level biophysiological factors, or higher level cognitive factors, is unknown.

METHODS

To explore the former, we analysed Skin Conductance Response (SCR, measuring sympathetic activity) amplitude and high frequency Heart Rate Variability (HRV, measuring parasympathetic activity) across two emotion induction paradigms, one involving narrations of personal experiences of self-disgust, shame and guilt, and one targeting self-disgust selectively via images of the self. Both paradigms had a neutral condition.

RESULTS

Photo paradigm elicited significant changes in physiological responses in patients relative to controls-higher percentages of HRV in the high frequency range but lower SCR amplitudes, with patients to present lower responses compared to controls. In the narration paradigm, only guilt condition elicited significant SCR differences between groups.

CONCLUSIONS

Consequently, lower level biophysiological factors are unlikely to cause elevated self-disgust levels in Parkinson's disease, which by implication suggests that higher level cognitive factors may be responsible.

Examining the Neurobiology of Non-Suicidal Self-Injury in Children and Adolescents: The Role of Reward Responsivity

Although prior work has shown heightened response to negative outcomes and reduced response to positive outcomes in youth with a history of non-suicidal self-injury (NSSI), little is known about the neural processes underlying these responses. Thus, this study examined associations between NSSI engagement and functional activation in specific regions of interest (ROIs) and whole-brain connectivity between striatal, frontal, and limbic region seeds during monetary and social reward tasks. To test for specificity of the influence of NSSI, analyses were conducted with and without depressive symptoms as a covariate. We found that NSSI was associated with decreased activation following monetary gains in all ROIs, even after controlling for depressive symptoms. Exploratory connectivity analyses found that NSSI was associated with differential connectivity between regions including the DS, vmPFC, insula, and parietal operculum cortex when controlling for depressive symptoms. Disrupted connectivity between these regions could suggest altered inhibitory control of emotions and pain processing in individuals with NSSI. Findings suggest dysfunctional reward processes in youth with NSSI, even very early in the course of the behavior.

Experiences and Situations of Shame among Food-insecure Adolescents in South Carolina and Oregon

Shame experienced with food insecurity and participating in food assistance may affect adolescents. We investigated adolescents' experiences of shame related to food insecurity and situations for these experiences in an ethnically diverse sample of 40 adolescents aged 9-15 years from South Carolina and Oregon. In-depth interviews were recorded, transcribed, coded, and analyzed. Participants described feelings of sadness, anger, and internalized shame with food insecurity. Salient situations were participating in food assistance, seeking food assistance from others or community services, and social encounters at school among peers. Adolescents felt shame knowing that peers were aware of their food insecurity and about them participating in food assistance through school.

Beliefs About One's Non-Suicidal Self-Injury: The Experiences of Self-Injury Questionnaire (ESIQ)

OBJECTIVE

The goal of this study was to develop and validate a measure of self-rated positive and negative beliefs about one's non-suicidal self-injury (NSSI), the Experiences of Self-Injury Questionnaire (ESIQ).

METHOD

Psychometric properties and validation against NSSI severity and shame were tested in two U.S. and two U.K. samples of individuals who endorsed a history of NSSI.

RESULTS

Exploratory and confirmatory factor analyses indicated five factors. Subscales were labeled Positive Beliefs, Personal Dislike, Interpersonal Concern, Emotional Suppression, and Emotional Expression. The Positive Beliefs Subscale covers beliefs that NSSI is valuable. Scores on this subscale were associated with endorsement of NSSI frequency, NSSI urges, and perceived likelihood of future NSSI. Other subscales showed validity in that they all showed unique effects on outcome indices of NSSI severity or shame.

CONCLUSION

The ESIQ shows promise as a brief reliable measure of beliefs about and experiences of NSSI.

Investigating self-concept in self-harm: A repertory grid study

OBJECTIVES

The way that individuals perceive themselves and others may be relevant in understanding difficulties with self-harm. Repertory grids provide a relatively underutilized means of investigating self-concept in people who self-harm. This study aimed to examine the association between self-concept, captured through a repertory grid method, and self-harm.

METHOD

Ninety-eight participants with a history of self-harm took part in the study. A repertory grid was used to derive distances between four elements ('current self', 'ideal self', 'self-harming self', and 'others who self-harm'). Associations between these distances and measures of self-harm behaviour, well-being and perceived recovery, were estimated.

RESULTS

Repertory grid distances were significantly associated with self-harm. When adjusting for covariates, self-harm in the past year was positively associated with a greater distance (or less perceived similarity) between current and ideal self, and a smaller distance (greater perceived similarity) between current self and others who self-harm. Repertory grid distances were also associated with well-being and perceived recovery.

CONCLUSIONS

The results are consistent with the idea that self-perception is associated with self-harm and related difficulties. The results also highlight the potential utility of repertory grids as a tool for exploring self-concept. The cross-sectional nature of the study precludes inferences about directionality or the temporal characteristics of associations.

PRACTITIONER POINTS

More recent experiences of self-harm may be reflected in the way individuals perceive or construe themselves. The way in which individuals who self-harm perceive or construe themselves may also be related to their current well-being and perceived recovery. Repertory grids may be a useful tool in clinical practice for investigating self-concept in those who self-harm. Repertory grids may provide a more idiographic, clinical outcome assessment in those who self-harm.

The relation between measures of explicit shame and borderline personality features in adolescent inpatients

BACKGROUND

Shame is a highly negative emotion frequently experienced by individuals with borderline personality disorder (BPD) as well as those with internalizing or externalizing psychopathology. However, few studies have examined whether shame is related to BPD above and beyond other psychopathology. Further, although feelings of shame peak during adolescence, coinciding with the onset of BPD, very few studies have examined the relationship between shame and BPD in adolescence. Therefore, the current study examined (1) whether levels of shame differ between adolescent psychiatric inpatients with and without BPD and (2) whether borderline personality pathology accounts for additional variance in the experience of shame above and beyond internalizing and externalizing psychopathology.

METHODS

Adolescent psychiatric inpatients (n = 184, 67% female, M age = 15.26) completed clinical interviews and self-report measures as well as self-report measures of three types of explicit shame: state-shame, shame-proneness, and trait-shame.

RESULTS

T-tests revealed that adolescents with BPD reported significantly higher levels of each type of explicit shame. In hierarchical regression models, borderline personality features explained significant additional variance in shame-proneness and trait-shame while controlling for age, gender, and internalizing and externalizing psychopathology.

LIMITATIONS

Our sample was limited by a lack of demographic diversity and healthy control group, and the study did not examine relations with unique internalizing/externalizing disorders or features of BPD.

CONCLUSIONS

Our findings contribute to growing evidence that shame is an important component of BPD, particularly during adolescence, and suggest that shame should be addressed in treatment.

Self-Contempt, the Working Alliance and Outcome in Treatments for Borderline Personality Disorder: An Exploratory Study

Objective. We examined the role of expressed self-contempt in therapy for borderline personality disorder (BPD). Based on previous literature on BPD, we assumed an association between the self-contempt and the core symptoms of BPD. We also studied the progression of expressed self-contempt during the treatment and its effect on the alliance and the outcomes of treatment.Method. We rated the expressed self-contempt in 148 tape-recorded sessions with patients with BPD (N = 50), during a brief psychiatric treatment. We rated self-contempt at three time-points, using an observer-rate scale. Self-reported questionnaires were used to assess symptoms and the working alliance.Results. There are some associations between self-contempt and BPD symptoms. Expressed self-contempt did not change during the treatment. One measure of self-contempt was associated with a weaker alliance rated by the patients and with a stronger alliance rated by the therapists. The expression of high self-contempt was not predictive of outcomes when the initial level of problems was controlled for.Conclusions. The results highlight the importance to examine the complex effects of self-contempt in BPD undergoing treatment in a differentiated manner and suggest to clinicians and researchers to be attentive to this specific emotional state, and change therein, in psychotherapy.Keywords: Self-contempt; Borderline Personality Disorder; Brief Treatment; Therapeutic Alliance; EmotionTrial registration: ClinicalTrials.gov identifier: NCT01896024.

Borderline personality disorder: from understanding ontological addiction to psychotherapeutic revolution

Bypassing a reductionist view of existing diagnostic categories, ontological addiction theory (OAT) is a new psychological model of human functioning. Borderline Personality Disorder (BPD), defined as "a pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity", is not only common (up to 20% of psychiatric inpatients), but also strongly associated with suicide attempts and death by suicide. Therefore, BPD constitutes a major public health concern. As a consequence of an underlying condition of ontological addiction, self-harming behaviors can be conceptualized as addictions, suicidal acts reflecting an experiential avoidance strategy against unbearable psychological pain. The present paper aims at: (1) understanding BPD daily life experiences from the perspective of OAT; (2) offering psychotherapeutic perspectives for this mental disorder. The diagnostic category of BDP may be understood as a simple label reflecting several extreme types of manifestations resulting from the Self-grasping ignorance that underpins ontological addiction. Therefore, development of psychotherapeutic interventions targeting ontological addiction appears to be a promising future direction.

Predicting engagement in nonsuicidal self-injury (NSSI) over the course of 12 months: the roles of borderline personality disorder pathology and emotional consequences of NSSI

BACKGROUND

Despite theories that negative reinforcement in the form of relief from negative emotions maintains nonsuicidal self-injury (NSSI), no studies have examined the extent to which specific emotional consequences of NSSI predict the maintenance of NSSI over time or explain the greater risk for NSSI found among individuals with borderline personality disorder (BPD) pathology. This study examined whether specific emotional consequences of NSSI relate to the continuance of NSSI behavior over a 12-month period and explain the relation of baseline BPD pathology to future NSSI.

METHODS

Participants with a history of recent repeated NSSI (N = 84) completed baseline measures of BPD pathology, NSSI, and the emotional antecedents and consequences of NSSI, including self-conscious emotions, undifferentiated negative affect, anger, emptiness, sadness, and anxiety; follow-up data on NSSI were collected every three months for one year.

RESULTS

Of the emotional consequences of NSSI examined here, only self-conscious emotions significantly predicted the presence and frequency of NSSI during the 12-month follow-up period. Likewise, whereas BPD pathology was not directly associated with later NSSI, both overall BPD pathology and the specific BPD feature of identity problems were indirectly related to the presence of 12-month NSSI through the greater frequency of post-NSSI self-conscious emotions.

LIMITATIONS

Emotional consequences of NSSI were assessed using a retrospective self-report measure. Only frequency, and not intensity, of emotions before and after NSSI were assessed.

CONCLUSIONS

Results suggest a distinct role of post-NSSI self-conscious emotions in the maintenance of NSSI among individuals with and without BPD pathology.

Neural basis of shame and guilt experience in women with borderline personality disorder

Borderline personality disorder (BPD) is characterized by instability of affect, emotion dysregulation, and interpersonal dysfunction. Especially shame and guilt, so-called self-conscious emotions, are of central clinical relevance to BPD. However, only few experimental studies have focused on shame or guilt in BPD and none investigated their neurobiological underpinnings. In the present functional magnetic resonance imaging study, we took a scenario-based approach to experimentally induce feelings of shame, guilt, and disgust with neutral scenarios as control condition. We included 19 women with BPD (age 26.4 ± 5.8 years; DSM-IV diagnosed; medicated) and 22 healthy female control subjects (age 26.4 ± 4.6 years; matched for age and verbal IQ). Compared to controls, women with BPD reported more intense feelings when being confronted with affective scenarios, especially higher levels of shame, guilt, and fear. We found increased amygdala reactivity in BPD compared to controls for shame and guilt, but not for disgust scenarios (p = 0.05 FWE corrected at the cluster level; p < 0.0001 cluster defining threshold). Exploratory analyses showed that this was caused by a diminished habituation in women with BPD relative to control participants. This effect was specific to guilt and shame scenarios as both groups showed amygdala habituation to disgust scenarios. Our work suggests that heightened shame and guilt experience in BPD is not related to increased amygdala activity per se, but rather to decreased habituation to self-conscious emotions. This provides an explanation for the inconsistencies in previous imaging work on amygdala involvement in BPD as well as the typically slow progress in the psychotherapy of dysfunctional self-conscious emotions in this patient group.

Evaluation of Self-Compassion Focused Group Treatment for Co-Occurring PTSD and Substance Use in Veterans with Posttraumatic Guilt: A Case Study

Co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD) following combat exposure affects a significant proportion of military veterans. Guilt and shame are common to PTSD-SUD, suggesting a possible role as a mechanism underlying both disorders. Cultivating self-compassion (SC) among veterans is a logical approach to treating guilt and shame. The purpose of this article is threefold: (a) present scientific theories of SC in the veteran population with emphasis on PTSD, substance use, and guilt and shame; (b) present a case study that highlights how self-compassion-focused treatment (SCFT) can be utilized in a group format with veterans with PTSD-SUD and posttraumatic guilt; and (c) discuss implications of our findings for refining SCFT within a group intervention setting among this population and for future research.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Shame and Suicidal Ideation among Undergraduates in China: The Mediating Effect of Thwarted Belongingness and Perceived Burdensomeness

Undergraduate students with shame are more likely to experience suicidal ideation, but there remains a lack of research investigating the factors underlying this relationship. The interpersonal theory of suicide posits that suicidal ideation is influenced by the simultaneous presence of thwarted belongingness and perceived burdensomeness. We examined the prevalence of suicidal ideation among undergraduate students in China and examined the association between shame and suicidal ideation mediated by perceived burdensomeness and thwarted belongingness. A survey was conducted in July 2018 involving 2320 undergraduate students, and the twelve-month prevalence of suicidal ideation was 8.95%. Shame played a crucial role in predicting suicidal ideation, and the mediating effects of perceived burdensomeness and thwarted belongingness between shame and suicidal ideation were significant. Suicidal ideation is common among undergraduate students in China and merits greater attention. Shame, perceived burdensomeness, and thwarted belongingness may be important factors to assess among undergraduate students in suicide risk assessment and psychological intervention.

An examination of the relationship between shame, guilt and self-harm: A systematic review and meta-analysis

Self-harm is a major public health concern associated with suicide risk and significant psychological distress. Theories suggest that aversive emotional states are an important process that drives self-harm. Shame and guilt may, in particular, be important emotions in self-harm. This review therefore sought to provide a systematic review and meta-analysis of the relationship between shame, guilt, and self-harm. A systematic search of electronic databases (PsycINFO; Medline; CINAHL Plus; Web of Science and ProQuest) was undertaken to identify studies measuring shame, guilt and self-harm (including suicidal and non-suicidal behaviour). Meta-analysis was undertaken where papers focused on the same subtype of shame or guilt and shared a common outcome. Thirty studies were identified for inclusion. Most forms of shame were associated with non-suicidal self-injury (NSSI), but research was sparse concerning suicidal behaviour. Fewer studies examined guilt and findings were more varied. Methodological issues included a paucity of longitudinal designs and lack of justification for sample sizes. Results of this review support the link between shame and self-harm, particularly NSSI. The direction of this relationship is yet to be established. Clinically, consideration should be given to the role of shame amongst individuals who present with NSSI. This review was pre-registered on PROSPERO (CRD42017056165).

Assessing the Validity of the Quartile Risk Model of Dissociation for Predicting Deliberate Self-Harm

Deliberate self-harm (DSH) involves a physical act with the intent of harming the self. There are many precipitants to this behavior, with dissociation receiving increasing attention. The current study examined the quartile risk model for predicting deliberate self-harm, which proposes that four quadrants of dissociation (low normative, high normative, low clinical, and high clinical) represent varying levels of risk for engagement in DSH. The model posits that quadrants one and three (low normative, low clinical), protect against engagement in deliberate self-harm. Quadrants two and four (high normative, high clinical), represent an increased risk of engaging in DSH. The current study also investigated the association between shame and deliberate self-harm. College students (n = 247) completed measures assessing trait dissociation, state and trait shame, and deliberate self-harm. Results did not support the quartile risk model, rather they suggested a general increasing level of deliberate self-harm with heightened dissociation. Furthermore, trait shame was significantly associated with deliberate self-harm. Significantly more state shame was found to occur before engaging in deliberate self-harm relative to after. Results suggest shame and dissociation are related to increased DSH.

Changes in the Indices of Body Image Concern, Sexual Self-Esteem and Sexual Body Image in Females Undergoing Cosmetic Rhinoplasty: A Single-Group Trial

INTRODUCTION

Psychological factors play a major role in the tendency toward cosmetic surgery. Variety seeking, making changes in one's face and reducing apparent dissatisfaction, improving body image and increasing sexual self-esteem can be considered as some psychological aspects of cosmetic surgery. The present study was conducted with the aim of evaluating the changes in the indices of body image concern, sexual self-esteem and sexual body image in patients undergoing rhinoplasty.

METHOD

This study was a single-group pretest-posttest quasi-experimental design. The research data were collected from March 2015 to January 2016. For this purpose, of the patients seeking nose surgery who referred to beauty centers in Mashhad, 40 subjects were selected through purposive method sampling and completed a Body Image Concern Inventory, Sexual Self-Esteem Index for Women and Body Exposure during Sexual Activities Questionnaire before and after rhinoplasty. These data were collected after obtaining informed consent, conducting a structured clinical interview and completing the demographic checklist.

FINDINGS

Data analysis demonstrated that there is a significant improvement in the index of female body image concern after rhinoplasty (p < 0.05). In the indices of sexual self-esteem and sexual body image, the analyses showed no significant difference between the pretest and posttest scores (p > 0.05).

CONCLUSION

Cosmetic surgery leads to the reduced body image concern of women but has no effect on sexual self-esteem and sexual body image. It seems that the psychological function of patients does not change significantly by rhinoplasty dimensions.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Distinguishing people with current, past, and no history of non-suicidal self-injury: Shame, social comparison, and self-concept integration

OBJECTIVE

Non-Suicidal Self-Injury (NSSI) can have a major impact on the lives of individuals and those around them. The way in which a person feels about and perceives themselves (i.e. self-concept) appears central to understanding NSSI. The current study investigates three variables linked to self-concept: shame, social comparison, and self-concept integration. We examine how well these variables differentiate people who report past NSSI, people who report current NSSI, and people who have never engaged in NSSI.

DESIGN

Cross-sectional.

METHOD

Individuals reporting NSSI in the past year (n = 51), individuals with a history of NSSI but none in the past year (n = 44), and individuals with no history of NSSI (n = 110) were compared on measures of shame, social comparison, and self-concept integration.

RESULTS

Shame was elevated in people with a history of NSSI but did not distinguish between past and current NSSI when other variables were controlled for. Self-concept integration was poorer in people reporting current NSSI than people reporting past NSSI, even when controlling for other variables.

CONCLUSIONS

The results support the role of shame as a general marker for NSSI risk, but suggest self-concept integration may fluctuate more dynamically in relation to the recency of NSSI. The study is limited by a non-matched student control group.

Assessment of Different Dimensions of Shame Proneness: Validation of the SHAME

A large body of research revealed that shame is associated with adaptive and maladaptive correlates. The aim of this work was to validate a new dimensional instrument (SHAME), which was developed to disentangle adaptive and maladaptive dimensions of shame proneness. Confirmatory factor analyses supported the three-factorial structure (bodily, cognitive, and existential shame) in American (n = 502) and German (n = 496) community samples, using invariance testing. Bifactor model analyses exhibited distinct associations of adaptive (bodily and cognitive shame) and maladaptive (existential shame) dimensions of shame with psychopathology and social functioning. Network analyses highlighted the role of existential shame in psychopathology, especially for a clinical sample of patients with Borderline Personality Disorder (n = 92). By placing shame pronenesss into a network of similar and dissimilar constructs, the current findings serve as a foundation for drawing conclusions about the adaptive and maladaptive nature of shame.

Is the association of deliberate self-harm with emotional relief stable or dependent on emotional context?

BACKGROUND AND OBJECTIVES

Despite strong support for the role of emotional relief in deliberate self-harm (DSH), no research has examined the impact of emotional distress on the strength of the DSH-relief association. Thus, it remains unclear whether the association of DSH with emotional relief is stable across emotional contexts or context-dependent. This study aimed to examine if the implicit DSH-relief association is stronger in the context of emotional distress (relative to a neutral emotional context).

METHODS

Young adult women with (n = 60) and without (n = 60) a history of recent recurrent DSH were randomly assigned to complete a novel version of the Implicit Association Test (IAT) assessing the DSH-relief association at baseline (following an initial neutral emotion induction) and again following either a neutral or negative (i.e., social rejection) emotion induction.

RESULTS

Consistent with hypotheses, the DSH-relief association was stronger among women with recent recurrent DSH (vs. those without DSH) at baseline. Contrary to hypotheses, however, whereas the DSH-relief association remained stable following both the neutral and negative emotion inductions among participants with DSH, it became stronger across both conditions for participants without DSH.

LIMITATIONS

The use of a community sample of young adult women may limit generalizability to other relevant populations (e.g., clinical populations, young men, adolescents). Additionally, the negative emotion induction may not have been powerful enough to affect the strength of the learned DSH-relief association among individuals with a repeated history of DSH.

CONCLUSIONS

Findings suggest that the repeated use of DSH to bring about emotional relief may engender associations of DSH with relief that are relatively insensitive to emotional context.

Are shame and self-esteem risk factors in prolonged grief after death of a spouse?

Although many single factors of prolonged grief have been identified in the literature, a comprehensive understanding of predictors is still lacking. This article argues that shame and low self-esteem, present risk factors in prolonged grief after spousal loss, based on a review of correlational studies. Using a practitioner-scientist approach, a developmental model of shame as a core factor in prolonged grief is proposed, outlining the progression from childhood relational trauma, to insecure attachment, shame, self-esteem contingent on spousal approval to eventual prolonged grief.

Expressed Emotion, Shame, and Non-Suicidal Self-Injury

A cross-sectional study examining relationships between perceived family Expressed Emotion and shame, emotional involvement, depression, anxiety, stress and non-suicidal self-injury, in 264 community and online adults (21.6% male). We compared self-injurers with non-self-injurers, and current with past self-injurers. Self-injurers experienced more family Expressed Emotion (EE) than non-injurers (t(254) = −3.24, p = 0.001), linear contrasts explaining 6% of between-groups variability (F(2, 254) = 7.36, p = 0.001, η² = 0.06). Differences in EE between current and past self-injurers were not significant. Overall shame accounted for 33% of between-groups variance (F(2, 252) = 61.99, p < 0.001, η² = 0.33), with linear contrasts indicating self-injurers experienced higher levels compared to non-injurers (t(252) = −8.23, p < 0.001). Current self-injurers reported higher overall shame than past self-injurers (t(252) = 6.78, p < 0.001). In further logistic regression, emotional involvement and overall shame were the only significant predictors of self-injury status. With every one-unit increase in emotional involvement, odds of currently engaging in self-injury decreased by a factor of 0.860. Conversely, a one-unit increase in overall shame was associated with an increase in the odds of being a current self-injurer by a factor of 1.05. The findings have important treatment implications for engaging key family members in intervention and prevention efforts.

The unique contribution of acceptance without judgment in predicting nonsuicidal self-injury after 20-weeks of dialectical behaviour therapy group skills training

The current research tested whether four dimensions of mindfulness - acceptance without judgment, observing, describing and acting with awareness - predicted frequency of nonsuicidal self-injury (NSSI) and mediate the relationship with NSSI outcomes during 20-weeks of Dialectical Behaviour Therapy (DBT) skills training for borderline personality disorder (BPD). Eighty-four self-harming individuals with BPD were randomized to either DBT skills training or to a waitlist control group. A series of regressions revealed no relationship between dimensions of mindfulness and NSSI at baseline. There was a significant effect of DBT skills training on NSSI. As well, mediation analysis indicated that acceptance without judgment, specifically, mediated the relation between DBT skills training and change in frequency of NSSI.

Suicidal Behavior and Problems with Emotion Regulation

We examined in two independent samples whether: (1) difficulties with emotion regulation predict suicide ideation and (2) depressed adults with a history of attempting suicide report and exhibit more emotion dysregulation compared to healthy and depressed controls. Difficulties with emotional clarity and relationship status were significant predictors of suicide ideation (Study 1). In Study 2, when compared to controls, depressed attempters reported significantly more difficulties with emotional clarity and emotional impulsivity. Attempters had significantly more difficulty than controls returning to heart rate baseline following a stressful task. Problems with emotions are therefore differentially connected to suicidal behaviors.

The Role of Negative Affect and Self-Concept Clarity in Predicting Self-Injurious Urges in Borderline Personality Disorder Using Ecological Momentary Assessment

Deficits in identity as well as negative affect have been shown to predict self-injurious and suicidal behaviors in individuals with borderline personality disorder (BPD). However, less is known about the interactive effects of these two predictors. We examined the moderating effect of a particular component of identity, self-concept, on the relationship between negative affect and self-injurious urges utilizing ecological momentary assessments. Outpatients diagnosed with either BPD (n = 36) or any anxiety disorder but no BPD (n = 18) completed surveys throughout the day over a 21-day period. Higher levels of momentary negative affect predicted greater subsequent urges to self-injure, but only when self-concept clarity was low (z = -3.60, p < .01). This effect did not differ between diagnostic groups. The results suggest that self-concept clarity has a protective effect against self-injurious urges in light of high negative affect, and that this effect may be transdiagnostic.

Non-suicidal self-injury and suicidal thoughts and behaviors: A study of the explanatory roles of the interpersonal theory variables among military service members and veterans

OBJECTIVE

Research has identified non-suicidal self-injury (NSSI) as a robust correlate of suicidal thoughts and behaviors; however, little is known regarding why these constructs may be related. Consistent with the interpersonal theory of suicide, this study investigated thwarted belongingness (TB), perceived burdensomeness (PB), and capability for suicide (CS) as explanatory links in the association between NSSI, ideation, and suicide attempt history.

METHOD

Military service members and veterans (N = 973; agemean = 29.9 years, 78.8% male, 63.8% Caucasian/White) completed measures of lifetime NSSI and suicide attempts; current suicidal ideation; TB, PB, and CS; and related psychiatric symptoms. Bootstrap moderated mediation analyses were employed to examine whether (a) TB moderated the mediating effect of PB on NSSI and ideation, (b) PB moderated the mediating effect of TB on NSSI and ideation, and (c) CS moderated the mediating effect of TB and PB on NSSI and attempts.

RESULTS

TB and PB significantly accounted for the relationship between lifetime NSSI and current ideation. TB did not moderate the mediating effect of PB on NSSI and ideation, and PB did not moderate the mediating effect of TB. However, CS significantly moderated the mediating effects of TB and PB on NSSI and attempt history.

CONCLUSIONS

The interpersonal theory of suicide hypotheses were partially supported. Consistent with the theory, the interaction of TB and PB only explained NSSI and attempt history among service members with high levels of CS. TB and PB only individually explained the association between lifetime NSSI and recent suicidal ideation. Prospective studies are warranted to replicate these findings across other military samples. (PsycINFO Database Record

To see in a mirror dimly. The looking glass self is self-shaming in borderline personality disorder

Symptoms of borderline personality disorder (BPD) can be conceptualized as the expression of and defenses against or response to the painful emotion of chronic shame, which may relate to early maladaptive schemas (EMS). The goal of this research is to examine levels of early maladaptive schemas, self-reported shame, and anxious or angry reactions to social put-downs as well as their associations. We also looked to assess the association of shame with BPD symptoms. Fifty-six patients with BPD completed self-report measures of EMSs, chronic shame, and reactions to put-downs. Comparison groups consisted of 24 patients without personality disorder (non-PD) and 80 healthy controls (HC). Those with BPD reported higher levels of EMSs, characterological, behavioral and bodily shame, and were more prone to react with anxiety and anger than non-PD patients and HC subjects. EMSs domains had specific associations with chronic shame and reaction types to social put-downs. Identity disturbances were associated with characterological, behavioral and bodily shame. Stormy relationships were associated with bodily shame. Chronic shame and anxious and angry reactions to social put-downs are prominent in patients with borderline personality disorder and are associated with specific EMS domains and with the symptoms of identity disturbance and stormy relationships.

On the Link between Perceived Parental Rearing Behaviors and Self-conscious Emotions in Adolescents

This study examined relationships between the self-conscious emotions of guilt and shame in both clinical (N = 104) and non-clinical (N = 477) (young) adolescents aged 11-18 years, who completed a questionnaire to assess perceived parental rearing behaviors (EMBU-C) and a scenario-based instrument to measure proneness to guilt and shame (SCEMAS). Results indicated that parental rearing dimensions were positively related to self-conscious emotions. Regarding the non-clinical sample, both favourable (emotional warmth) and unfavourable (rejection) paternal and maternal rearing dimensions were significant correlates of guilt- and shame-proneness. The results for the clinical sample were less conclusive: only maternal emotional warmth and rejection were found to be significantly associated with guilt and shame. Interestingly, no associations between any of the paternal rearing dimensions and self-conscious emotions emerged. Taken together, these results are in keeping with the notion that parental rearing factors are involved in the development of both adaptive and maladaptive self-conscious emotions in adolescents.

Factor structure, factorial invariance, and validity of the Multidimensional Shame-Related Response Inventory-21 (MSRI-21)

We describe 2 studies designed to evaluate scores on the Multidimensional Shame-related Response Inventory-21 (MSRI-21), a recently developed instrument that measures affective and behavioral responses to shame. The inventory assesses shame-related responses in 3 categories: negative self-evaluation, fear of social consequences, and maladaptive behavior tendency. For Study 1, (N = 743) undergraduates completed the MSRI-21. Confirmatory factor analysis supported the validity of the MSRI-21 3-factor structure. Latent variable modeling of coefficient-α provided strong evidence for the internal consistency of scores on each scale. In Study 2, (N = 540) undergraduates completed the instrument along with 5 concurrent measures chosen for clinical significance. Achievement of factorial invariance supported the use of MSRI-21 scale scores to make valid mean comparisons across gender. In addition, MSRI-21 scale scores were associated as expected with scores on measures of self-harm, suicide, and other risk factors. Taken together, results of 2 studies support the internal consistency reliability, factorial validity, factorial invariance, and convergent validity of scores on the MSRI-21. Further work is needed to assess the temporal stability of the MSRI-21 scale scores, invariance across clinical status and other groupings, item-level measurement properties, and viability in highly symptomatic samples. (PsycINFO Database Record

Examining the Impact of Suicide Attempt Function and Perceived Effectiveness in Predicting Reattempt for Emergency Medicine Patients

While previous studies have examined motivational aspects of self-directed violence, few studies have included specific motivations in predictive models for future suicide attempts. The current study utilized a sample of 160 individuals treated in an acute emergency setting following a suicide attempt who completed an interview battery that included an assessment of functional aspects of the index suicide attempt. A follow-up interview was conducted at 6 months to ascertain subsequent suicide attempts. The functional domains of suicide attempts were labeled as reduction-of-distress, communication, perceived better alternative to living, and self-loathing. Above and beyond other known risk factors, including history and highest lethality of previous self-injury, suicide attempts that served a communication function (OR = 0.18, p = .02, CI = 0.04, 0.73) and higher ratings of clinical dysfunction (OR = 3.41, p = .05, CI = 1.02, 11.36) were associated with a significant reduction in likelihood to engage in a suicide attempt during the 6-month follow-up window. Including the perceived effectiveness of the index suicide attempt in getting one's needs met strengthened the overall model predicting a suicide attempt in the follow-up window and was an independent risk factor above and beyond other variables in the model OR = 1.75, p = .04, CI = 1.02, 3.01). Assessment of functional aspects of suicide attempt is feasible and may improve formulation of risk in a population where typical risk factors for suicide are ubiquitous.

Cross-sectional and temporal association between non-suicidal self-injury and suicidal ideation in young adults: The explanatory roles of thwarted belongingness and perceived burdensomeness

Non-suicidal self-injury (NSSI) is a strong predictor of suicidal ideation and attempts. Consistent with the interpersonal theory of suicide, preliminary evidence suggests that NSSI is associated with higher levels of perceived burdensomeness (PB) and thwarted belongingness (TB). However, no study to date has examined the cross-sectional and prospective relationships between NSSI, TB, PB, and suicidal ideation (SI). To fill this gap, this study examined the mediating role of TB and PB in the relationship between NSSI and SI at baseline and follow-up. Young adults (N=49) with and without histories of NSSI completed self-report measures of TB, PB, and SI at three time points over two months. NSSI history was associated with higher levels of PB, TB, and SI at all time points. TB and PB significantly accounted for the relationship between NSSI history and SI at baseline. However, the relationship between NSSI history and SI at follow-up was mediated by PB, not TB. Findings provide evidence for the roles of TB and PB in the relationship between NSSI and SI, and partial support for the interpersonal theory of suicide. Future research and clinical implications are discussed.

Impact of Non-Suicidal Self-Injury Scale: Initial Psychometric Validation

The current study examined the psychometric properties of the Impact of Non-Suicidal Self-Injury Scale (INS), a scale developed to assess the social, behavioral, and emotional consequences of engaging in non-suicidal self-injury (NSSI). University students (N=128) who endorsed a history of NSSI were administered the INS, as well as measures of hypothesized convergent and divergent validity. Results suggested that the INS is best conceptualized as a one-factor scale, and internal consistency analyses indicated excellent reliability. The INS was significantly correlated with well-known measures of NSSI severity (i.e., NSSI frequency, NSSI recency), and measures of suicide attempt history and emotional reactivity. Logistic regression analyses indicated that the INS contributed unique variance to the prediction of physical disfigurement (i.e., NSSI scarring) and clinically significant social anxiety, even after taking into account NSSI frequency. Furthermore, the INS demonstrated divergent validity. Implications for research on NSSI disorder and clinical practice are discussed.

Self-compassion and emotional invalidation mediate the effects of parental indifference on psychopathology

This study investigated whether self-compassion and emotional invalidation (perceiving others as indifferent to one's emotions) may explain the relationship of childhood exposure to adverse parenting and adult psychopathology in psychiatric outpatients (N=326). Path analysis was used to investigate associations between exposure to adverse parenting (abuse and indifference), self-compassion, emotional invalidation, and mental health when controlling for gender and age. Self-compassion was strongly inversely associated with emotional invalidation, suggesting that a schema that others will be unsympathetic or indifferent toward one's emotions may affect self-compassion and vice versa. Both self-compassion and emotional invalidation mediated the relationship between parental indifference and mental health outcomes. These preliminary findings suggest the potential utility of self-compassion and emotional schemas as transdiagnostic treatment targets.

Intrapersonal characteristics of body-related guilt, shame, pride, and envy in Canadian adults

This study examined differences in body-related shame, guilt, pride, and envy based on intrapersonal characteristics of sex, age, and weight status in 527 Canadian adults. Compared to men, women reported significantly higher shame and guilt contextualized to the body. No sex differences were observed for envy or pride. Middle-aged adults reported higher shame and lower pride compared with young adults, whereas no age differences were observed with body-related guilt. Meanwhile, shame and guilt were highest for individuals who had overweight or obese weight status, and pride was highest in individuals with average weight status. Overall, effect sizes were small and there were no significant interaction effects between sex, age, and weight status across body-related emotions. Further research is needed to capture similarities and differences of body-related self-conscious emotions between intrapersonal characteristics, to aid the development of intervention strategies to manage this important dimension of body image.

Daily shame and hostile irritability in adolescent girls with borderline personality disorder symptoms

Recent theoretical and empirical work suggests that adults with borderline personality disorder (BPD) have difficulty regulating both shame and anger, and that these emotions may be functionally related in clinically relevant ways (e.g., Schoenleber & Berenbaum, 2012b). The covariation of shame with anger-related emotions has important clinical implications for interventions targeting shame and uncontrolled anger in BPD. However, no studies have examined shame, anger, and their covariation in adolescents who may be at risk for developing BPD. Therefore, this study focuses on associations between BPD symptoms and patterns of covariation between daily experiences of shame and anger-related affects (i.e., hostile irritability) in a community sample of adolescent girls using ecological momentary assessment. Multilevel models revealed that girls with greater BPD symptoms who reported greater mean levels of shame across the week also tended to report more hostile irritability, even after controlling for guilt. Additionally, examination of within-person variability showed that girls with greater BPD symptoms reported more hostile irritability on occasions when they also reported greater concurrent shame, but this was only the case in girls of average socioeconomic status (i.e., those not receiving public assistance). Unlike shame, guilt was not associated with hostile irritability in girls with greater BPD symptoms. Results suggest that shame may be a key clinical target in the treatment of anger-related difficulties among adolescent girls with BPD symptoms.