Mechanisms of change in an emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder

Evaluation of the level of training of French psychiatrists on borderline personality disorder: An online survey

BACKGROUND

Borderline personality disorder is a common and treatable personality disorder that is often underdiagnosed and untreated, mainly due to a lack of training of psychiatrists and to a lack of accessibility to specialized therapies. However, no study has been conducted in France regarding this issue. Thus, we aimed to evaluate on a national scale the level of training, knowledge, and general attitude toward BPD diagnosis of French psychiatrists.

METHODS

We conducted an online survey in an unselected population of residents and senior French psychiatrists between January and March 2022, the results of which are presented descriptively.

RESULTS

228 psychiatrists fully answered the questionnaire, and 21 more psychiatrists answered it partially. We found that most of the responders were unsatisfied with the residency training or the continuing medical education offered regarding BPD, a lack of training resulting in a low level of self-confidence regarding BPD management, in a low number of evidence-based therapies trained psychiatrists in issues regarding diagnostic disclosure, and in misconceptions regarding some aspects of the disorder.

CONCLUSIONS

These results underlie a clear lack of training of French psychiatrists, as well as a request from the latter for more opportunities to learn. This calls for a rethinking of the teaching system to incorporate more knowledge and tools related to BPD.

"It's ok that I feel like this": a qualitative study of adolescents' and parents' experiences of facilitators, mechanisms of change and outcomes in a joint emotion regulation group skills training

BACKGROUND

Emotion regulation difficulties underlie several psychiatric conditions, and treatments that focus on improving emotion regulation can have an effect on a broad range of symptoms. However, participants' in-depth experiences of participating in emotion regulation treatments have not been much studied. In this qualitative study, we investigated participants' experiences of a joint emotion regulation group skills training in a child and adolescent psychiatric outpatient setting.

METHODS

Twenty-one participants (10 adolescents and 11 parents) were interviewed about their experiences after they had participated in a seven-session transdiagnostic emotion regulation skills training for adolescents and parents. The aim of the skills training was to decrease emotion regulation difficulties, increase emotional awareness, reduce psychiatric symptoms, and enhance quality of life. The skills training consisted of psychoeducation about emotions and skills for regulating emotions. The interviews were transcribed and analysed using reflexive thematic analysis.

RESULTS

The analysis resulted in three overarching themes: Parent - Child processes, Individual processes, and Group processes. The result showed that participants considered an improved parent-child relationship to be the main outcome. Increased knowledge, emotion regulation skills and behavioural change were conceptualised as both mechanisms of change and outcomes. The group format, and the fact that parents and adolescents participated together, were seen as facilitators. Furthermore, the participants experienced targeting emotions in skills training as meaningful and helpful.

CONCLUSION

The results highlight the potential benefits of providing emotion regulation skills training for adolescents and parents together in a group format to improve the parent-child relationship and enable the opportunity to learn skills.

Measuring Emotion Regulation Skill Use During Treatment: A Promising Methodological Approach

Emotion regulation has become ubiquitous in the study of psychopathology and a growing number of treatment outcome studies are collecting data on emotion regulation skill use. However, traditional measures of emotion regulation fail to capture important nuances in emotion regulation processes, their relationship to psychopathology, and how individuals use emotion regulation skills over time and across contexts. Novel methodologies are particularly needed for measuring emotion regulation in the context of treatment studies. In this article, we discuss a proposed methodology, the combination of ecological momentary assessment (EMA), and single-case experimental design (SCED), for measuring emotion regulation strategy use in the context of treatment outcome studies. To inform this discussion, we provide a brief overview of common approaches to assessing emotion regulation skill use in the context of treatment outcome research. We then describe the utility of intensive data capture (EMA) in the context of idiographic treatment studies (SCED), present a case study to illustrate the different uses of data collected through EMA in the context of a SCED study, and discuss considerations for implementing this method in clinical practice.

Psychometric properties of an Arabic translation of the brief version of the difficulty in emotion regulation scale (DERS-16)

BACKGROUND

The current study aimed to examine the psychometric properties of an Arabic translation of the short form of the Difficulty in Emotion Regulation Scale (DERS-16) in an Arabic-speaking population-based adult sample in Lebanon. In particular, the factorial structure, composite reliability, convergent validity and gender invariance were investigated.

METHODS

A total of 411 Lebanese adult participants (mean age of 32.86 ± 11.98 years, 75.4% females) took part of this cross-sectional web-based study. The forward and backward translation method was applied.

RESULTS

Findings revealed good internal consistency of the Arabic DERS-16 total scale and five subscales (McDonald's ω ranging from 0.81 to 0.95). Confirmatory factor analyses confirmed the five-factor solution of the scale and demonstrated strong measurement invariance across gender at the configural, metric, and scalar levels. No significant differences were found in all DERS-16 domains between men and women participants. Finally, the DERS-16 scores and sub-scores showed strong correlations with the Borderline Personality Questionnaire (r > .40), thus indicating its convergent validity.

CONCLUSION

Overall, the present findings suggest that the Arabic version of the DERS-16 may be a reliable and valid self-report measure that assesses ER difficulties as a multidimensional construct. Making the Arabic version of the DERS-16 available will hopefully strengthen its utilization for clinical and research purposes to benefit the millions of Arabic-speaking people worldwide.

Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science

Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.

Eating disorder behaviors as a form of non-suicidal self-injury

Nonsuicidal Self-Injury (NSSI), the purposeful harming of one's body tissue without suicidal intent. NSSI frequently co-occurs with other self-destructive forms of psychopathology, such as eating disorders (ED); however, it remains unclear if ED behaviors are used as a form of NSSI. This exploratory study examined the occurrence of Self-Injurious Disordered Eating Symptoms (SIDES), as well as differences in clinical correlates and treatment outcomes between NSSI patients with and without SIDES. Participants included 1,327 patients admitted for partial hospitalization or intensive outpatient treatment for NSSI (87.4% female; 75.3% Non-Hispanic White). Data were collected at admission and discharge as part of routine clinical outcome assessment. Results indicate that 29.5% of the sample engaged in SIDES, while most were not diagnosed with an ED. Patients that engaged in SIDES reported greater clinical severity at baseline, including greater general psychopathology, lower quality of life, and worse functional impairment, as well as more clinically severe NSSI (e.g., greater number of methods, higher urge to self-injure, greater intrapersonal functions). No differences in treatment outcomes were found. These findings suggest that some NSSI patients perceive ED behaviors as a form of NSSI and that SIDES may be a marker for a more severe clinical presentation.

New horizons in group psychotherapy research and practice from third wave positive psychology: a practice-friendly review

Group psychotherapy has been shown to be equivalent to individual therapy for many disorders, including anxiety, depression, grief, eating disorders, and schizophrenia (Burlingame & Strauss, 2021). In addition to effectiveness in reducing symptoms, group offers members a sense of belonging, purpose, hope, altruism, and meaning throughout treatment (Yalom & Leszcz, 2020). These additional outcomes are especially important considering the COVID-19 pandemic and national/international conflicts, given the trauma, disruptions, and losses people have experienced. Applying recent developments in positive psychology to group therapy can enhance treatment. A practice-friendly review examined recent advances in the positive psychology literature, demonstrating how group therapy offers members unique growth opportunities in addition to reducing symptoms. Key findings from studies applying positive psychological constructs to group therapy outcomes are synthesized. Our review sheds light on the relevance of third wave positive psychology to enrich group therapy (Lomas et al., 2021). Specifically, group therapy can facilitate the development of vitalizing psychological virtues, and these can be used to assess treatment outcome: humanity, wisdom, transcendence, courage, temperance, and justice. Interrelatedly, we present support for including attachment theory and mentalization within a positive psychological group framework. Implications are explored for group therapy research, clinical work, and training.

Enhancing member engagement in a Tier 3 personality disorder service during COVID-19: evaluation of a virtual group programme

BACKGROUND

Drop-out rates from evidence-based interventions for people with a diagnosis of personality disorder (PD) are high. The COVID-19 pandemic has likely exacerbated barriers to engagement with the introduction of virtual working. Virtual therapy has a good evidence-base for Axis I disorders, but limited research for Axis II disorders.

AIMS

To investigate facilitators and barriers to engagement in a Tier 3 PD service virtual group programme.

METHOD

A virtual group programme was developed in collaboration with service members, and analysed members' attendance rates over a 5-month period pre- and post-COVID-19. Thematic analysis of semi-structured telephone interviews with 38 members is reported, describing their experience of the virtual group programme.

RESULTS

Attendance rates were significantly higher pre-COVID (72%) than post-COVID (50%). Thematic analysis highlighted key barriers to attendance were: practical issues, low motivation, challenges of working in a group online and feeling triggered at home. Main promoters of engagement were: feeling valued, continued sense of connection and maintaining focus on recovery.

DISCUSSION

The results suggest that the pandemic has exacerbated relational and practical barriers to engagement in a Tier 3 PD service. Ways of enhancing engagement are discussed, as well as preliminary recommendation for services offering virtual therapy to people with a diagnosis of PD.

Non-response to psychotherapy for borderline personality disorder: A systematic review

HIGHLIGHT

This is the first systematic review to investigate non-response to psychotherapy for borderline personality disorder.

BACKGROUND

Psychotherapy is the recommended treatment for borderline personality disorder. While systematic reviews have demonstrated the effectiveness of psychotherapy for borderline personality disorder, effect sizes remain small and influenced by bias. Furthermore, the proportion of people who do not respond to treatment is seldom reported or analysed.

OBJECTIVE

To obtain an informed estimate of the proportion of people who do not respond to psychotherapy for borderline personality disorder.

METHODS

Systematic searches of five databases, PubMed, Web of Science, Scopus, PsycINFO and the Cochrane Library, occurred in November 2020. Inclusion criteria: participants diagnosed with borderline personality disorder, treated with psychotherapy and data reporting either (a) the proportion of the sample that experienced 'reliable change' or (b) the percentage of sample that no longer met criteria for borderline personality disorder at conclusion of therapy. Exclusion criteria: studies published prior to 1980 or not in English. Of the 19,517 studies identified, 28 met inclusion criteria.

RESULTS

Twenty-eight studies were included in the review comprising a total of 2436 participants. Average treatment duration was 11 months using well-known evidence-based approaches. Approximately half did not respond to treatment; M = 48.80% (SD = 22.77).

LIMITATIONS

Data regarding within sample variability and non-response are seldom reported. Methods of reporting data on dosage and comorbidities were highly divergent which precluded the ability to conduct predictive analyses. Other limitations include lack of sensitivity analysis, and studies published in English only.

CONCLUSION

Results of this review suggest that a large proportion of people are not responding to psychotherapy for borderline personality disorder and that factors relating to non-response are both elusive and inconsistently reported. Novel, tailored or enhanced interventions are needed to improve outcomes for individuals not responding to current established treatments.

Evaluation of the Affect School as supplementary treatment of Swedish women with eating disorders: a randomized clinical trial

BACKGROUND

Despite solid research there remains a large group of patients with eating disorders who do not recover. Emotion dysregulation has been shown to be a feature in the different eating disorders. A manualized group intervention developed in Sweden, the Affect School, aims to enhance emotional awareness and the ability to perceive and express emotions.

AIM

This study aimed to test the hypothesis that participation in the Affect School as a complement to ordinary eating disorder treatment would enhance awareness and regulation of emotions and reduce alexithymia and cognitive eating disorder symptoms in a sample of patients with eating disorders at a Swedish specialized outpatient clinic.

METHOD

Forty patients with various eating disorders were randomized to either participation in the Affect School as a supplement to treatment as usual (TAU), or to a TAU control group. Participants were assessed with the Eating Disorder Examination Questionnaire, the Deficits in Emotion Regulation Scale-36, and the Toronto Alexithymia Scale-20 at start, end of intervention, and at the 6- and 12-month follow-ups.

RESULTS

No significant differences were observed post-treatment but Affect School participants had improved significantly more than controls on eating disorder cognitions and behaviours and emotion dysregulation at the 6- and 12-month follow-ups and had significantly less alexithymia at the 6-month follow-up.

CONCLUSION

Difficulties with emotion recognition and/or regulation can complicate fulfilment of personal needs and obstruct communication and relationships with others. The present study indicates that adding Affect School group sessions to regular treatment enhances emotional awareness and emotion regulation and decreases eating disorder symptoms and alexithymia. Patients with eating disorder diagnoses have described problems with emotional management, for example: lower emotional awareness and difficulties in using adaptive emotional regulatory strategies compared to people without eating disorders. It has been suggested that interventions aiming at enhancing emotional awareness and acceptance would be beneficial in treatment. In the present study we explored whether adding the Affect School to regular treatment would enhance awareness and regulation of emotions and decrease eating disorder symptoms. Forty women with an eating disorder were randomly allocated to either an additional participation in a group treatment for 8 weeks or usual treatment only. The treatment contained education on different affects such as joy, fear, interest, shame, anger, disgust, and worry. The education was followed by discussions on own experiences. Participants filled in self-assessment forms that measured eating disorder symptoms, emotional recognition, and emotion regulation before the start and at the end of the group treatment, and after 6 and 12 months respectively. The results when comparing the two groups suggested that the Affect School could be an effective additional treatment. Participants in the Affect School improved their scorings but the change took time and did not show until at the 6- and 12 months follow-ups.

Emotion Regulation Difficulties and Health-Risk Behaviours in Adolescents

Health-Risk Behaviours (HRBs) are significantly associated with avoidable mortality in adolescents, and preventing HRBs requires an adequate understanding of related factors. Among associated factors, emotion regulation difficulties may impact youths’ engagement in HRBs. Researchers explored the relation of emotion regulation with HRBs; however, specific emotion regulation difficulties for less severe and more prevalent HRBs, such as self-harming behaviour, risky-driving, violence, unhealthy dietary behaviour, and poor adherence to prescribed medication, has not been much explored. The current study aimed to explore the predictability of adolescents’ specific difficulties in emotion regulation in relation to their engagement in HRBs. For this purpose, six different HRBs, that is, self-harm, violence, risky-driving, unhealthy dietary behaviour, inadequate physical activity, and lack of medication adherence, were studied. A total of 617 (Males = 356) adolescents (Mage = 15.77) from five districts of Punjab state (India) provided required information on standardised self-report measures. The data were subjected to regression analysis, and the findings show that the participants who scored high on emotion regulation difficulties reported engagement in HRBs more than their counterparts. Some specific difficulties are more important than others for different forms of HRBs. It implies that the intervention programmes targeting specific HRBs should address specific facets of emotional dysregulation.

Managing emotions in psychosis: Evaluation of a brief DBT-informed skill group for individuals with psychosis in routine community services

Objectives

Individuals with psychosis report that emotion regulation (ER) difficulties are treatment priorities, yet little is known about how targeted ER interventions may help. We evaluated a new eight‐session Dialectical Behavioural Therapy (DBT)–informed skills group specifically adapted for individuals with psychosis: the Managing Emotions Group (MEG) in diverse, inner‐city community services.

Method

A mixed‐method design was utilised to assess the feasibility (acceptability and potential clinical impact) of local delivery of MEG. Uptake, completion (≥50% of sessions), post‐session satisfaction ratings, and thematic analysis of qualitative feedback from 12 completers assessed acceptability. Pre–post‐intervention changes in psychological distress, self‐reported ER difficulties, and adaptive ER skill use assessed potential clinical impact.

Results

Forty‐eight individuals (81% of attenders) completed the intervention (M_age = 43, 54% female) of whom 39 completed pre‐ and post‐group measures. Participants reported high satisfaction and meaningful improvements in understanding and managing emotions, with positive impact on daily life. Self‐reported psychological distress, ER difficulties, and adaptive ER skill use significantly improved, with medium‐to‐large pre‐post effects (d = 0.5–0.7) except lack of emotional clarity (d = 0.3).

Conclusions

MEG was feasible and acceptable, and a future feasibility randomised controlled trial is warranted.

Practitioner points

Individuals with psychosis report that support with their emotions is a priority.

Brief interventions for emotion regulation difficulties are acceptable to individuals with psychosis and can be feasibly delivered in a local outpatient service.

Distress and emotion regulation difficulties and skills improved significantly from pre–post treatment for clients completing the managing emotions group.

Further implementation and evaluation are needed to support continued refinement to meet the needs and priorities of individuals with psychosis.

Micro-level de-coupling of negative affect and binge eating in relationship to macro-level outcomes in binge eating disorder treatment

BACKGROUND

While negative affect reliably predicts binge eating, it is unknown how this association may decrease or 'de-couple' during treatment for binge eating disorder (BED), whether such change is greater in treatments targeting emotion regulation, or how such change predicts outcome. This study utilized multi-wave ecological momentary assessment (EMA) to assess changes in the momentary association between negative affect and subsequent binge-eating symptoms during Integrative Cognitive Affective Therapy (ICAT-BED) and Cognitive Behavior Therapy Guided Self-Help (CBTgsh). It was predicted that there would be stronger de-coupling effects in ICAT-BED compared to CBTgsh given the focus on emotion regulation skills in ICAT-BED and that greater de-coupling would predict outcomes.

METHODS

Adults with BED were randomized to ICAT-BED or CBTgsh and completed 1-week EMA protocols and the Eating Disorder Examination (EDE) at pre-treatment, end-of-treatment, and 6-month follow-up (final N = 78). De-coupling was operationalized as a change in momentary associations between negative affect and binge-eating symptoms from pre-treatment to end-of-treatment.

RESULTS

There was a significant de-coupling effect at follow-up but not end-of-treatment, and de-coupling did not differ between ICAT-BED and CBTgsh. Less de-coupling was associated with higher end-of-treatment EDE global scores at end-of-treatment and higher binge frequency at follow-up.

CONCLUSIONS

Both ICAT-BED and CBTgsh were associated with de-coupling of momentary negative affect and binge-eating symptoms, which in turn relate to cognitive and behavioral treatment outcomes. Future research is warranted to identify differential mechanisms of change across ICAT-BED and CBTgsh. Results also highlight the importance of developing momentary interventions to more effectively de-couple negative affect and binge eating.

Borderline personality disorder

Borderline personality disorder (BPD) is a mental disorder with a high burden on patients, family members, and health-care systems. The condition was previously regarded as untreatable, but progress in understanding and management has resulted in earlier diagnosis and better treatment outcomes. A coherent syndrome of BPD typically onsets during adolescence (after age 12 years). BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both. BPD is associated with various poor outcomes, including low occupational and educational attainment, lack of long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use. Psychotherapy is the main treatment for BPD; drug treatment is only indicated for comorbid conditions that require medication, or during a crisis if psychosocial interventions are insufficient. Awareness of BPD by non-specialists, as well as specialists, is key to appropriate early intervention.

Experiences of an Online Treatment for Adolescents With Nonsuicidal Self-injury and Their Caregivers: Qualitative Study

Background

Nonsuicidal self-injury (NSSI) is common in adolescence and is associated with several adverse outcomes. Despite this, few established treatment options exist. Online treatment seems promising for several conditions; however, knowledge on NSSI is scarce. It is important to explore how online treatment for NSSI is experienced to improve such interventions and learn more about factors that are important in the treatment of adolescents with NSSI.

Objective

This study aims to explore the experiences of a novel online treatment for adolescents with NSSI and their caregivers.

Methods

A qualitative study using thematic analysis was conducted through semistructured interviews with 9 adolescents and 11 caregivers at treatment termination or at the 6-month follow-up of the online emotion regulation individual therapy for adolescents.

Results

A total of 3 overarching themes were identified. The theme support can come in different shapes showed how support could be attained through both interaction with the therapist as well as through the format itself (such as through the fictional characters in the material and the mobile app). Caregivers found it helpful to have their own online course, and adolescents accepted their involvement. The theme self-responsibility can be empowering as well as distressing showed that self-responsibility was highly appreciated (such as deciding when and how to engage in treatment) but also challenging; it caused occasional distress for some. The theme acquiring new skills and treatment effects showed the advantages and challenges of learning several different emotion regulation skills and that decreased emotion regulation difficulties were important treatment outcomes for adolescents. In addition, several different skills seemed to facilitate emotion regulation, and having access to such skills could hinder NSSI.

Conclusions

Online emotion regulation individual therapy for adolescents seems to offer an accepted way to deliver family interventions for this target group; facilitate skills training with several means of support, including support from both the mobile app and the therapist; contribute to decreasing emotion regulation difficulties and teaching skills that could hinder NSSI; and cause (in some individuals) distress because of the self-responsibility that is inherent to online formats, which needs to be addressed.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Understanding predictors of change in a day treatment setting for non-suicidal self-injury

OBJECTIVES

To examine change in non-suicidal self-injury (NSSI) frequency, quality of life, and functional impairment from admission to discharge in patients enrolled in partial hospitalization and intensive outpatient programmes (PHP/IOP) designed to treat NSSI. Demographic, clinical, and treatment-related predictors of changes were also examined.

DESIGN

Data were collected as part of routine clinical assessment procedures at admission and discharge from patients enrolled in a PHP/IOP programme designed to treat NSSI. The clinical assessment included measures examining quality of life, functional impairment, and NSSI behaviour.

METHODS

Paired t-tests were used to examine change in NSSI frequency, quality of life, and functional impairment. Reliable clinical change analyses were used to identify clinically significant change in quality of life and functional impairment. Multilevel mixed-effects regression was used to examine predictors of change for quality of life and functional impairment. Negative binomial regression was used to examine predictors of change for NSSI frequency.

RESULTS

From admission to discharge, NSSI frequency significantly decreased and quality of life and functional impairment evidenced clinically significant change. Age, race/ethnicity, and insurance type predicted change in functional impairment, while gender predicted change in quality of life. Urge to self-injure predicted change in NSSI frequency. Borderline symptoms predicted change across all outcome variables.

CONCLUSIONS

Patients who completed a day treatment programme for NSSI evidenced significant change in NSSI frequency, functional impairment, and quality of life at discharge; however, several demographic and clinical variables were associated with change.

PRACTITIONER POINTS

Patients who engage in NSSI show significant change from admission to discharge in a day treatment programme dedicated to the treatment of NSSI. Quality of life and functional impairment are important outcome variables to consider and evaluate in higher levels of care. It is important to consider demographic and clinical variables when creating a treatment plan for NSSI. Although BPD symptoms may be important to consider in day treatment for NSSI, interpersonal dysfunction, depressive symptoms, and mood lability may also affect change in symptoms.

Clinical Characteristics and Self-Harm in Forensic Psychiatric Patients

Self-harm, comprising non-suicidal self-injury, and suicide attempts, is a serious and potentially life-threatening behavior that has been associated with poor life quality and an increased risk of suicide. In forensic populations, increased rates of self-harm have been reported, and suicide is one of the leading causes of death. Aside from associations between self-harm and mental disorders, knowledge on self-harm in forensic psychiatric populations is limited. The purpose of this study was to characterize the clinical needs of a cohort of forensic psychiatric patients, including self-harm and possible risk factors thereof. Participants (N = 98) were consecutively recruited from a cohort of forensic psychiatric patients in Sweden from 2016 to 2020. Data were collected through file information, self-reports, and complemented with semi-structured interviews. Results showed that self-harm was common among the participants, more than half (68.4%) of whom had at some point engaged in self-harm. The most common methods of non-suicidal self-injury were banging one's head or fist against a wall or other solid surface and cutting, and the most common method of suicide attempt was hanging. The most prominent functions of non-suicidal self-injury among the participants were intrapersonal functions such as affect regulation, self-punishment, and marking distress. Self-harm in general was associated to neurodevelopmental disorders (p = 0.014, CI = 1.23-8.02, OR = 3.14) and disruptive impulse-control and conduct disorders (p = 0.012, CI = 1.19-74.6, OR = 9.41), with reservation to very wide confidence intervals. Conclusions drawn from this study are that self-harm was highly prevalent in this sample and seems to have similar function in this group of individuals as in other studied clinical and non-clinical groups.

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.

REMOTION Blended Transdiagnostic Intervention for Symptom Reduction and Improvement of Emotion Regulation in an Outpatient Psychotherapeutic Setting: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Emotion regulation has been identified as an important transdiagnostic factor relevant to the treatment of mental health disorders. Many empirically validated psychotherapeutic treatments incorporate elements targeting emotion regulation. Most of these treatment approaches are conceptualized as standard face-to-face treatments not as blended treatments, which include an internet-based intervention.

OBJECTIVE

The aim of this study is to examine, for the first time, a new internet-based intervention-REMOTION-that will be provided transdiagnostically, as an add-on to psychotherapy, to provide a blended treatment format.

METHODS

A total of 70 participants will be assigned (1:1 allocation ratio) to either the intervention group (REMOTION + psychotherapy) or the treatment-as-usual group that receives psychotherapy alone. To maximize external validity, a typical outpatient treatment sample of patients diagnosed with a range of disorders such as depression, anxiety disorders, and adjustment disorder will be recruited from a university outpatient clinic. Patients with bipolar disorder, psychotic disorders, or acute suicidality will be excluded from the study. The feasibility and potential effectiveness of the intervention will be examined by assessing data at baseline, 6 weeks (post), and 12 weeks (follow-up). The primary outcome is general symptom severity, assessed with the Brief Symptom Inventory. Secondary outcomes are emotion regulation, depressive symptoms, anxiety symptoms, health related quality of life, well-being, and a variety of feasibility parameters. Quantitative data will be analyzed on an intention-to-treat basis.

RESULTS

Participant recruitment and data collection started in February 2020, and as of November 2020, are ongoing. Results for the study are expected in 2022.

CONCLUSIONS

This pilot randomized controlled trial will inform future studies using transdiagnostic blended treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04262726; http://clinicaltrials.gov/ct2/show/NCT04262726.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20936.

Feasibility and predictors of change of narrative exposure therapy for displaced populations: a repeated measures design

BACKGROUND

Displaced victims of interpersonal violence, such as refugees, asylum seekers, and victims of sexual exploitation, are growing in numbers and are often suffering from a post-traumatic stress disorder (PTSD). At the same time, these victims are known to benefit less from trauma-focused therapy (TFT) and to be less compliant to treatment. The objective of this paper is to describe the rationale and research protocol of an ongoing trial that aims to evaluate different variables that might influence the feasibility of TFT for the study population. Specifically, perceived daily stress, emotion regulation, and mood are investigated as predictors of change in PTSD symptoms during a trauma-focused therapy (narrative exposure therapy (NET)). The feasibility of administering measures tapping these constructs repeatedly during treatment will also be evaluated.

METHODS/DESIGN

Using an observational treatment design, 80 displaced victims of interpersonal violence will be measured before, during, and after partaking in NET. Several questionnaires tapping PTSD plus the aforementioned possible predictors of PTSD change will be administered: Post-traumatic Stress Disorder Checklist-5, Perceived Stress Scale, Difficulties in Emotion Regulation Scale-18 (pre-test, post-test, and follow-up),subscale impulsivity of the Difficulties in Emotion Regulation Scale-18, Perceived Stress Scale short version, Primary Care Post-traumatic Stress Disorder and a single Mood item (each session). Multilevel modelling will be used to examine the relation between the possible predictors and treatment outcome.

DISCUSSION

The present study is the first to examine the interplay of facilitating and interfering factors possibly impacting treatment feasibility and effectiveness in displaced victims of interpersonal violence with PTSD receiving NET, using repeated measures. The current study can help to improve future treatment based on individual characteristics.

TRIAL REGISTRATION

Netherlands Trial Register: NTR7353, retrospectively registered. Date of registration: July 11, 2018.

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.

Processes of Change in Psychotherapy for Narcissistic Personality Disorder

The present study aims at determining the role for outcome of potential processes of change in psychotherapy for narcissistic personality disorder (NPD). They were examined on three levels: the content, the process, and the relationship. A total of 161 patients suffering with NPD were recruited in a naturalistic setting as part of the present study. They underwent a long- term clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video- or audio-recorded and analyzed with an observer-rated instrument that measures the quality of the interaction processes from the patient's and therapist's perspectives. Different self-report measures were used to assess therapy outcomes. In-session improvement was observed in both patient and therapist processes across sessions. Patient improvement in the three levels of processes was systematically related with outcome. Only partial relationships were found between therapist improvement and outcome. The present study represents the first systematic insight into core changes in patients with NPD undergoing psychotherapy.

Emotion regulation group skills training for adolescents and parents: A pilot study of an add-on treatment in a clinical setting

Difficulties with emotion regulation have been identified as an underlying mechanism in mental health. This pilot study aimed at examining whether group skills training in emotion regulation for adolescents and parents as an add-on intervention was feasible in an outpatient child and adolescent psychiatric clinic. We also investigated if the treatment increased knowledge and awareness of emotions and their functions, increased emotion regulation skills and decreased self-reported symptoms of anxiety and depression. Six skills training groups were piloted with a total of 20 adolescents and 21 adults. The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired-samples t test was used to compare differences between before-and-after measures for adolescents and parents separately. The primary outcome measure, Difficulties in Emotion Regulation Scale, showed significant improvement after treatment for both adolescents and parents. For adolescents, measures of alexithymia were significantly reduced. Also, emotional awareness was significantly increased. Measures of depression and anxiety did not change. In conclusion, group skills training as an add-on treatment can be feasible and effective but further studies are needed.

Psychosocial Interventions for People Who Self-Harm: Methodological Issues Involved in Trials to Evaluate Effectiveness

We have assessed the methodological quality of randomized controlled trials (RCTs) of interventions to prevent self-harm repetition and suicide. Trials were identified in two systematic reviews of RCTs of psychosocial treatments following a recent (within six months) episode of self-harm indexed in any of five electronic databases (CCDANCTR-Studies and References, CENTRAL, Medline, Embase, and PsycINFO) between 1 January, 1998 and 29 April, 2015. A total of 66 trials were included, 55 in adults and 11 in children and adolescents. While evidence for efficacy of some approaches has grown, there were few trials from low-to-middle income countries, little information on interventions for males, information on the control condition was often limited, data on suicides were often not reported, and, while trials have increased in size in recent years, most have included too few participants to detect clinically significant results. There are major limitations in many trials of interventions for individuals who self-harm. Improved methodology, especially with regard to study size, provision of details of control therapy, and evaluation of key outcomes, would enhance the evidence base for clinicians and service users.

Recent developments in psychosocial interventions for borderline personality disorder

Borderline personality disorder (BPD) is a serious psychiatric disorder that affects multiple symptomatic domains and is associated with an increased risk of suicidality. Several empirically supported treatments for BPD have been developed in recent years for adults with BPD. More recent work has focused on tailoring or applying (or both) these existing treatments to specific patient populations, including patients with certain types of comorbidity (for example, BPD and post-traumatic stress disorder or antisocial personality disorder) and younger patients. Other work has involved developing treatments and models of treatment delivery that address concerns related to access of care. Relatedly, new adjunctive and technology-assisted interventions have been developed, adding to the growing repertoire of treatment options for these patients. Advances in the last several years address specific treatment needs and offer cost-efficient options for this diverse patient population.

Effects of self-injurious thoughts and behaviors and sexual risk-taking behaviors through emotional control

BACKGROUND

College students are at increased risk for self-injurious thoughts and behaviors (SITB) and sexual risk behaviors (SRB). Although students with a history of SITB appear to be more prone to SRB, the mechanisms linking these risk behaviors remain largely unexplored. Previous research points to emotional control (EC), defined as one's awareness and adaptability of emotions, as a potential mechanism explaining the relationship between SITB and SRB.1 METHODS: Data included 722 college students attending two different universities in the northeast and southeast regions of the United States. Multiple group structural equation models were fit to estimate the direct and indirect effects of history of SITB (suicidal ideation, attempt, and nonsuicidal self-injury) and EC on SRB jointly across men and women.

RESULTS

Findings supported indirect relationships between SITB and SRB through dysregulated EC, with type of SITB and patterns of SRB differing between men and women. For women, history of suicidal ideation and nonsuicidal self-injury were indirectly related to increased SRB through dysregulated EC. For men, history of suicidal ideation showed an indirect relationship on SRB through EC.

LIMITATIONS

Although this study employed random sampling, limitations include a cross-sectional design, which does not allow for causal inference, and reliance on self-report assessment data.

CONCLUSIONS

College students with a history of SITB who experience dysregulated EC may be more likely to engage in risky sexual behavior. Clinicians working with college students should concomitantly consider suicide and self-injury with SRB and consider interventions to improve EC.

Extending research on Emotion Regulation Individual Therapy for Adolescents (ERITA) with nonsuicidal self-injury disorder: open pilot trial and mediation analysis of a novel online version

BACKGROUND

Nonsuicidal self-injury (NSSI) is common among adolescents and associated with negative outcomes. However, treatments developed specifically for NSSI and the proposed NSSI disorder (NSSID) are scarce, and access to empirically supported treatments for NSSI in many areas is limited. Online treatments carry the potential to increase the availability of evidence-based treatments. Emotion regulation individual therapy for adolescents (ERITA) has shown promise in the treatment of adolescents with NSSID.

METHOD

The present study examined the feasibility, acceptability, and utility of an online version of ERITA. Twenty-five adolescents (aged 13-17) with NSSID and their parents were included in an uncontrolled open trial. Self-report and clinician-rated assessments of outcomes such as NSSI, self-destructive behaviors, emotion dysregulation, and global functioning were administered at pre-treatment, post-treatment, 3- and 6- month follow-up. Measures of NSSI, self-destructive behaviors, and emotion dysregulation were also assessed weekly during treatment.

RESULTS

Ratings of treatment credibility, expectancy, and satisfaction were acceptable, and the therapeutic alliance and treatment completion rate (96%) were high. Adolescent participation in the treatment was associated with a statistically significant increase in past-month NSSI abstinence (p = .007), large-sized improvements in past-month NSSI frequency (55% reduction, 95% confidence interval [CI]: 29, 72; Cohen's d = 0.88, 95% CI: 0.73, 1.06) and global functioning (d = 1.01, 95% CI: 0.77, 1.32), and medium-sized improvements in emotion dysregulation (d = 0.75, 95% CI: 0.59, 0.90) and NSSI versatility (d = 0.63, 95% CI: 0.54, 0.77) from pre- to post-treatment. These improvements were further strengthened at 3-month follow-up and maintained at 6-month follow-up. The online therapist-guided parent program was associated with small- to large-sized (ds = 0.47-1.22) improvements in adaptive parent behaviors, and these improvements were maintained or further improved upon at 6-month follow-up. Moreover, in line with the theoretical model underlying ERITA, change in emotion dysregulation mediated changes in both NSSI frequency and self-destructive behaviors over the course of treatment.

CONCLUSIONS

Together, results suggest that online ERITA is an acceptable, feasible, and promising low-intensity treatment for adolescents with NSSID. The results of this open trial must be replicated in controlled studies.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02697019 ). Registered 2 March 2016.

Prevention of violent revictimization in depressed patients with an add-on internet-based emotion regulation training (iERT): study protocol for a multicenter randomized controlled trial

BACKGROUND

Psychiatric patients are at high risk of becoming victim of a violent crime compared to the general population. Although most research has focused on patients with severe mental illness, depressed patients have been demonstrated to be prone to victimization as well. Victimization is associated with more severe symptomatology, decreased quality of life, and high risk of revictimization. Hence, there is a strong need for interventions that focus on preventing violent revictimization. Since emotion dysregulation is associated with both victimization and depression, we developed an internet-based Emotion Regulation Training (iERT) to reduce revictimization in depressed patients. This study aims to evaluate the clinical and cost-effectiveness of iERT added to Treatment As Usual (TAU) in reducing incidents of violent revictimization among depressed patients with a recent history of victimization. Furthermore, this study aims to examine secondary clinical outcomes, and moderators and mediators that may be associated with treatment outcomes.

METHODS

In a multicenter randomized controlled trial with parallel group design, patients with a major depressive disorder and a history of violent victimization over the past three years (N = 200) will be allocated to either TAU + iERT (N = 100) or TAU only (N = 100), based on computer-generated stratified block randomization. Assessments will take place at baseline, 8 weeks, 14 weeks, and 6 months after start of treatment, and 12, 24, and 36 months after baseline. The primary outcome measure is the total number of violent victimization incidents at 12 months after baseline, measured with the Safety Monitor: an adequate self-report questionnaire that assesses victimization over the preceding 12 months. Secondary outcome measures and mediators include emotion dysregulation and depressive symptomatology. An economic evaluation with the societal perspective will be performed alongside the trial.

DISCUSSION

This study is the first to examine the effectiveness of an intervention aimed at reducing violent revictimization in depressed patients. If effective, iERT can be implemented in mental health care, and contribute to the well-being of depressed patients. Furthermore, the results will provide insight into underlying mechanisms of revictimization.

TRIAL REGISTRATION

The study is registered at the Netherlands Trial Register ( NTR5822 ). Date of registration: 4 April 2016.

Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: a feasibility study

BACKGROUND

Nonsuicidal self-injury (NSSI) is a serious health risk behavior that forms the basis of a tentative diagnosis in DSM-5, NSSI Disorder (NSSID). To date, established treatments specific to NSSI or NSSID are scarce. As a first step in evaluating the feasibility, acceptability, and utility of a novel treatment for adolescents with NSSID, we conducted an open trial of emotion regulation individual therapy for adolescents (ERITA): a 12-week, behavioral treatment aimed at directly targeting both NSSI and its proposed underlying mechanism of emotion regulation difficulties.

METHODS

Seventeen girls (aged 13-17; mean = 15.31) with NSSID were enrolled in a study adopting an uncontrolled open trial design with self-report and clinician-rated assessments of NSSI and other self-destructive behaviors, emotion regulation difficulties, borderline personality features, and global functioning administered at pre-treatment, post-treatment, and 6-month follow-up. Measures of NSSI and emotion regulation difficulties were also administered weekly during treatment.

RESULTS

Ratings of treatment credibility and expectancy and the treatment completion rate (88%) were satisfactory, and both therapeutic alliance and treatment attendance were strong. Intent-to-treat analyses revealed significant improvements associated with large effect sizes in past-month NSSI frequency, emotion regulation difficulties, self-destructive behaviors, and global functioning, as well as a medium effect size in past-month NSSI versatility, from pre- to post-treatment. Further, all of these improvements were either maintained or further improved upon at 6-month follow-up. Finally, change in emotion regulation difficulties mediated improvements in NSSI over the course of treatment.

CONCLUSIONS

Results suggest the acceptability, feasibility, and utility of this treatment for adolescents with NSSID.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02326012, December 22, 2014, retrospectively registered).

Growth curves of clients' emotional experience and their association with emotion regulation and symptoms

OBJECTIVE

Emotional experience during psychotherapy is considered a core mechanism of change. Yet the sheer experience itself may not necessarily be beneficial; instead, the trajectories of emotional experience need to be explored as possible predictors of treatment outcomes. This study investigated whether clients' pre-treatment levels of emotion regulation and symptoms predicted patterns of session-to-session change in emotional experience. We also explored which patterns better predict clients' improvement in emotion regulation and symptoms from pre- to post treatment.

METHOD

One-hundred and seven clients undergoing psychodynamic psychotherapy completed questionnaires on their symptoms and emotion regulation at pre- and post- treatment. They also reported their level of emotional experience at the end of each session.

RESULTS

Pre-treatment symptoms and difficulties in emotion regulation predicted greater instability in emotional experience. Higher mean levels of emotional experience during treatment were associated with an improvement in emotion regulation, and greater stability during treatment was associated with improvement in emotion regulation and symptoms.

CONCLUSIONS

These findings lend weight to the idea that experiencing emotion in the therapeutic environment has significant implications for clients' ability to manage their emotions outside the session. However, emotions experienced in an unstable manner within therapy are associated with poorer outcomes. Clinical and methodological significance of this article: Therapists can benefit from observing the patterns and not only the level of their clients' emotional experiences. The identification of clients' difficulties early in treatment may help therapists guide clients through the delicate process of carefully attending to their emotions.

Stability or instability in avoidant personality disorder:Mode fluctuations within schema therapy sessions

BACKGROUND AND OBJECTIVES

Avoidant personality disorder (APD) is among the most prevalent personality disorders, but has received relatively little empirical attention. This study aims to characterize the frequency, intensity, and fluctuation patterns seen in the modes (self-states) of APD clients over the course of schema therapy (ST), a psychotherapy approach developed especially for personality disorders.

METHOD

The newly-developed client mode rating scale (CMRS) was used to code every 5-min segment (n = 645) of 60 ST sessions. Each segment was coded by two independent raters, achieving adequate reliability.

RESULTS

The avoidant/detached mode was present in 74% of therapy segments and was the most intense and unstable mode; the vulnerable child mode was present in 58% of segments and was the second most intense and unstable mode; the dysfunctional parent mode was present in 40% of segments, and was the third most intense and unstable mode; the over-compensator, compliant-surrenderer, and healthy adult modes were present in around 33% of segments, but the healthy adult mode was significantly more stable than all others.

LIMITATIONS

Although 645 segments were coded, they were drawn from only 15 APD clients with no control group. Further studies are needed to established specificity to APD.

CONCLUSIONS

This study demonstrates the utility of the mode concept as a lexicon for capturing personality states and their instability. It highlights the use of in-session segment-by-segment ratings to assess client change within psychotherapy. Although DSM5 fails to address instability as a criterion for avoidant personality disorder, the APD clients in the current study were characterized by considerable mode instability.

Thoughts, images, and appraisals associated with acting and not acting on the urge to self-injure

OBJECTIVES

The aim of this study was to examine the frequency, content, and appraisals of thoughts and images occurring during urges to engage in non-suicidal self-injury (NSSI).

METHOD

Undergraduates (N = 154) with a history of NSSI completed an online survey of their thoughts, images, and appraisals when they acted on urges to engage in NSSI as well as when they resisted urges to self-injure.

RESULTS

Most (>90%) participants reported experiencing both thoughts and images during urges to engage in NSSI. During urges that resulted in self-injury, self-critical and hopeless thoughts were most distressing, and thoughts about relief from emotional distress were most comforting. Images of the anticipated injury were most common. During urges that did not result in self-injury themes of the futility of NSSI, positive self-talk, and the impact on others were most common. Images were most frequently of the negative impact on self and others, and the anticipated injury. Appraisals encouraging NSSI occurred when individuals did and did not act on their urges, but concurrent strong discouraging appraisals appeared to be protective on occasions when urges did not result in self-injury.

LIMITATIONS

Retrospective self-report was used to assess cognitive content. Generalisability of findings to non-student samples needs to be assessed.

CONCLUSIONS

Findings from this study may inform comprehensive assessment of thoughts and images associated with urges to engage in NSSI. NSSI interventions may need to promote thoughts, imagery and appraisals that discourage NSSI whilst simultaneously modifying cognitions that encourage NSSI.

Effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Among Veterans With Posttraumatic Stress Disorder: A Pilot Study

Effective treatment options are needed for veterans who do not participate in trauma-focused psychotherapy. Research has yet to examine the effectiveness of transdiagnostic psychotherapy in veterans with posttraumatic stress disorder (PTSD) and co-occurring psychological disorders. This pilot study examined the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a 16-week group format. We examined treatment outcomes in male and female veterans ( n = 52) in an outpatient specialty PTSD clinic at a large Veterans Affairs (VA) medical center. We hypothesized significant decreases in emotion regulation difficulty (Difficulties in Emotion Regulation Scale), PTSD symptom severity (PTSD Checklist for DSM-5), and depressive symptom severity (Patient Health Questionnaire-9). In addition, we hypothesized that reductions in emotion regulation difficulty across treatment would negatively predict PTSD and depressive symptoms at posttreatment. PTSD symptoms, depressive symptoms, and emotion regulation difficulty all evidenced significant improvements at the end of treatment relative to baseline ( ps < .001). In addition, reductions in emotion regulation across treatment were associated with lower PTSD and depressive symptoms at posttreatment ( ps < .001). This pilot study provides preliminary evidence supporting use of UP among veterans with PTSD and co-occurring disorders. Well-designed clinical trials evaluating efficacy of UP among veterans are needed.

Intimate Partner Violence and HIV-Risk Behaviors: Evaluating Avoidant Coping as a Moderator

Women who experience intimate partner violence (IPV) report higher rates of HIV-risk behaviors. However, few studies have examined factors that may influence the strength of the link between IPV and HIV-risk behaviors. The goal of the current study was to extend extant research by evaluating the potential moderating role of avoidant coping in this relation. Participants were 212 women currently experiencing IPV (M age = 36.63, 70.8 % African American) who were recruited from the community. Significant positive associations were found between physical, psychological, and sexual IPV severity and both avoidant coping and HIV-risk behaviors. Avoidant coping moderated the relations between both physical and psychological IPV severity and HIV-risk behaviors, such that physical and psychological IPV severity were significantly associated with HIV-risk behaviors when avoidant coping was high (but not low). Findings underscore avoidant coping as an important factor in identifying and subsequently treating IPV-victimized women vulnerable to HIV-risk behaviors.

Aggressive behavior and self-harm in Borderline Personality Disorder: The role of impulsivity and emotion dysregulation in a sample of outpatients

Impulsivity has often been related to aggressive and self-mutilative behavior in Borderline Personality Disorder (BPD). Many authors focused on the key role of emotion dysregulation in explaining vulnerability to dysfunctional behavior in BPD in addition to trait impulsivity. Furthermore, recent works have shed light on a gap in empirical research concerning the specific mechanisms by which a lack of affective regulation produces aggression proneness. The purpose of the study was to investigate the role of impulsivity and emotion dysregulation in determining vulnerability to aggression and deliberate self-harm in a sample of BPD outpatients. Enrolled patients with BPD (N =79) completed a comprehensive assessment for personality disorder symptoms, trait impulsivity, emotional dysregulation, aggressive and self - mutilative behavior. Trait impulsivity significantly predicted both aggressive and self-mutilative proneness. Furthermore, emotion dysregulation was found significantly to account for the vulnerability to aggression and self-injury, in addition to the variance explained by impulsivity. In conclusion, these findings support evidence that emotion dysregulation plays an important role in increasing the risk of dysfunctional behavior in impulsive BPD individuals.

Emotional Processes in Borderline Personality Disorder: An Update for Clinical Practice

Despite prior assumptions about poor prognosis, the surge in research on borderline personality disorder (BPD) over the past several decades shows that it is treatable and can have a good prognosis. Prominent theories of BPD highlight the importance of emotional dysfunction as core to this disorder. However, recent empirical research suggests a more nuanced view of emotional dysfunction in BPD. This research is reviewed in the present article, with a view towards how these laboratory-based findings can influence clinical work with individuals suffering from BPD.

“I Do Want to Stop, At Least I Think I Do”: An International Comparison of Recovery From Nonsuicidal Self-Injury Among Young People

Phenomenological and cultural understandings of recovery from the perspective of individuals who engage in nonsuicidal self-injury (NSSI) are rare. The primary study objective was to understand similarities across three samples in (a) how young people define recovery from NSSI and (b) what they consider helpful approaches taken by parents and professionals to assist their recovery. Using a cross-national sample of young people ( n = 98) from Australia ( n = 48), Belgium ( n = 25) and the United States ( n = 25), we assessed their perspectives on NSSI. Consistent across all samples, young people defined recovery as no longer having the urge to self-injure when distressed, often displayed ambivalence about recovery, and reported it was helpful when parents and professionals were calm and understanding. Acceptance of recovery as a process involving relapses may need to be emphasized in NSSI treatment, to ease the pressure young people often place on themselves to stop the behavior outright.