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

Effect of Dialectical Behavior Therapy on Negative Affect, and Symptoms of Depression and Anxiety in Individuals with Borderline Personality Disorder during COVID-19 Pandemic

Background: This study investigated the effectiveness of dialectical behavior therapy (DBT) in patients with borderline personality disorder (BPD) during the COVID-19 pandemic, assessing negative affect, depression, and anxiety levels as indicators of health. Methods: A total of 287 participants were recruited, including BPD patients at different stages of treatment and the general population without a diagnosis of BPD. Questionnaires were used to assess the fear of COVID-19 and the referenced health indicators. Results: No differences were observed between groups in levels of fear of COVID-19, but there were differences in the health indicators studied. BPD patients in long-term treatment showed levels of negative affect similar to those of the general population, while those in early treatment stages exhibited significantly higher levels. However, no significant improvements were observed in levels of depression and anxiety in the long-term treatment group compared to those who underwent the initial treatment phase. Conclusions: These findings underscore the importance of effectively intervening in BPD, especially in stress-inducing situations such as the pandemic, and suggest the need to explore complementary approaches to addressing depression and anxiety in this clinical context.

Feasibility and Efficacy of Intensive Dialectical Behavior Therapy Skills Training in An Outpatient Setting for A Group of Patients with Extensive Care Needs - A Transdiagnostic Approach

PURPOSE

Dialectical behavior therapy (DBT) is a treatment originally developed för chronically suicidal adults. It is common to adapt it by using one specific component, the DBT skills training (DBT-ST) and apply it in a group therapy setting for a variety of mental disorders. The primary aim of the study was to explore whether patients with extended care needs would report improved mental health after participating in an intensive form of DBT-ST. The secondary aim was to explore whether the use of psychiatric inpatient care for the group would decrease.

METHODS

Thirty-seven participants completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), and visual analogue scale (VAS) at three time points: pre-intervention, post-intervention and at 6-month follow-up after intensive DBT-ST.

RESULTS

One-way ANOVA showed a significant effect for time on the CORE-OM: F (2,35) = 7.93, p = .001, η2 = 0.312 (large effect size). Post hoc tests indicated a significant difference between pre-intervention and post-intervention (p = .001) and between pre-intervention and follow-up (p = .01). A Friedman test indicated a statistically significant difference in the VAS scale scores across the three time points, with p-values between 0.00 and 0.05. There was no difference in psychiatric healthcare consumption.

CONCLUSION

These study results confirm to some extent the feasibility and effectiveness of the intensive DBT-ST in a transdiagnostic clinical setting. The participants had a positive outcome from the skills training program, but psychiatric healthcare consumption did not decrease.

Mechanisms of change in treatments for transdiagnostic emotion dysregulation: The roles of skills use, perceived control and mindfulness

Emotion dysregulation (ED) is a key target for change among empirically supported treatments for emotional disorders, including dialectical behaviour therapy skills training (DBT-ST), yet how treatments improve ED is poorly understood. Using data from a randomised trial of DBT-ST versus supportive group therapy for transdiagnostic ED, we tested whether three mechanistic variables-behavioural skills use, mindfulness, and perceived control-explain variability in ED within people over time. We additionally explored the mediating roles of these variables between conditions. Adults with transdiagnostic ED (N = 44) participated in weekly groups for 4 months, with assessments at pre-, mid- and post-treatment and at 2-month follow-up. As hypothesised, multilevel models disaggregating within- and between-person effects indicated that skills use, mindfulness, and perceived control each had significant total and unique within-person associations with ED at concurrent time points, net the effect of time. Unexpectedly, these within-person relations were not significant for mechanistic variables predicting ED 2 months later. Further, unique between-person variability in skills use, mindfulness, and perceived control did not significantly mediate the relationship between condition and ED improvements. The present study is an important step in clarifying ED mechanisms of change, both within and between persons.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Does trait mindfulness mediate the relationship between borderline personality symptoms and emotion dysregulation?

BACKGROUND

Emotion dysregulation is core to many biopsychosocial models of Borderline Personality Disorder (BPD) and is often targeted as part of their associated psychological therapies. Several distinct specialist psychotherapies are thought to be effective for people diagnosed with BPD but it is unclear whether they share common change mechanisms. Some evidence suggests that Mindfulness Based Interventions improve competency in emotion regulation as well as trait mindfulness, which are both plausibly associated with good treatment outcomes. It is unclear whether the association between the severity of BPD symptoms and emotion dysregulation is mediated by trait mindfulness. Would improvement in trait mindfulness mediate an association between lower severity of BPD symptoms and fewer problems of emotion dysregulation?

METHODS

One thousand and twelve participants completed online, single time-point, self-report questionnaires.

RESULTS

As predicted, the severity of BPD symptoms was significantly and positively associated with emotion dysregulation with a large effect size (r = .77). Trait mindfulness mediated this relationship as the 95% confidence interval for the indirect effect did not cross zero (size of direct effect = .48 and size of indirect effect = .29 [.25, .33].

CONCLUSIONS

The relationship between the severity of BPD symptoms and emotion dysregulation was confirmed in this dataset. As hypothesised, this relationship was mediated by trait mindfulness. Process measures of emotion dysregulation and mindfulness should be included in intervention studies for people diagnosed with BPD to understand if improvements in these factors are a universal occurrence with good response to treatment. Other process measures should also be explored to identify other factors involved in the relationship between BPD symptoms and emotion dysregulation.

Parent-Adolescent Conflict, Depressive Symptoms, and Non-Suicidal Self-Injury among Chinese Adolescents: The Moderating Effect of the COMT Gene rs4680 Polymorphism

Existing research suggests that parent-adolescent conflict is associated with increased risk for adolescent non-suicidal self-injury (NSSI). However, adolescent NSSI reactions to parent-adolescent conflicts exhibit large individual differences. This study sought to explore whether depressive symptoms mediates the relationship between parent-adolescent conflict and adolescent NSSI, and whether this mediating process is moderated by the COMT gene rs4680 polymorphism. A total of 673 adolescents (364 males, 309 females) in the age range of 12 to 15 years (Mean_age = 12.81 years, SD = 0.48) completed questionnaires regarding parent-adolescent conflict, depressive symptoms, and NSSI. Genomic DNA was extracted from saliva and buccal cells from each participant. Bootstrapping techniques displayed statistically significant moderated mediation. The results showed that the positive association between parent-adolescent conflict and adolescent NSSI was in fact mediated by depressive symptoms. Moreover, this indirect link was moderated by the COMT gene rs4680 polymorphism. Specifically, the risk effect of parent-adolescent conflict on adolescent NSSI via depressive symptoms was stronger for adolescents with Val/Val genotype than for those with Met/Met or Val/Met genotype. These findings underscore the importance of examining the interaction between genes and the environment to understand how and when parent-adolescent conflict impacts adolescent NSSI.

Mindfulness as taught in DBT: a scoping review

This scoping review considers Eleven studies that have focussed on the effect of teaching the mindfulness element of Dialectical Behaviour Therapy (DBT) on clinical outcomes. These articles utilised either mindfulness skills as embedded into the full DBT-Skills program or a stand-alone mindfulness skills module (DBT-M), as treatment for clinical populations. The review of the research found that clinical application of mindfulness as taught in DBT leads to increases in self-reported mindfulness - especially non-judgemental awareness along with psychological measures that suggests an increase in mindfulness e.g. improved attention. The studies demonstrated that an increase in mindfulness had a positive effect on some clinical symptoms such as symptoms of Borderline Personality Disorder. Not all of the studies controlled for the effect of group, amount of practice or other elements of DBT therapy. The findings suggest that more needs to be done to establish the underlying mechanisms of change when being taught mindfulness in DBT.

Targeting self-criticism in the treatment of nonsuicidal self-injury in dialectical behavior therapy for adolescents: a randomized clinical trial

BACKGROUND

The Benefits and Barriers Model proposes both benefits and barriers associated with nonsuicidal self-injury (NSSI) and that a negative association with the self plays a key role in the initial selection of and acute motivation for NSSI. The current investigation builds upon previous findings by assessing the added benefit of targeting self-criticism in the treatment of NSSI.

METHODS

Sample included 40 participants (30 females; M_age  = 14.92) enrolled in dialectical behavior therapy for adolescents within a partial hospitalization program. All study participants received dialectical behavior therapy for adolescents, and those randomized to the experimental condition received an additional brief cognitive intervention developed to decrease self-criticism.

RESULTS

There was no evidence of an indirect effect of targeting self-criticism upon NSSI at post-treatment via post-treatment self-criticism (b = -0.98, p = .543); however, there was evidence of a significant interaction between treatment condition and self-criticism at pretreatment in the prediction of NSSI at post-treatment (b = 0.33, p = .030). Analyses of simple slopes indicated the conditional direct effect of targeting self-criticism varied as a function of patient's level of self-criticism at the onset of treatment, such that individuals -1 SD below the mean (b = -5.76, p = .037) and at average pretreatment levels of self-criticism (b = -4.09, p = .042), but not + 1 SD above the mean (b = -2.42, p = .056), experienced fewer incidents of NSSI at post-treatment.

CONCLUSIONS

The results of this investigation support the added benefit of targeting self-criticism in the treatment of NSSI for adolescents.

Cyberbullying victimization and nonsuicidal self-injury in adolescents: The role of maladaptive schemas and dispositional mindfulness

BACKGROUND

Previous research has found associations between cyberbullying victimization and nonsuicidal self-injury (NSSI) in adolescents. Exploration of the possible mediating variables involved is necessary to support intervention with victims.

OBJECTIVE

This study examined whether depression and early maladaptive schemas (EMS) mediate the association between cyberbullying victimization and NSSI, along with the potential protective role of dispositional mindfulness.

PARTICIPANTS AND SETTING

A total of 742 Spanish adolescents (50.20% girls) between 12 and 17 years old (M = 14.58; SD = 1.00) participated in the final sample.

METHOD

Participants completed measures of cyberbullying victimization, NSSI, EMS, depression, and mindfulness facets. Mediational models moderated by facets of mindfulness were tested.

RESULTS

Cyberbullying victimization was associated with NSSI through increased depression and EMS. Acting with awareness buffered the association between cyberbullying victimization and NSSI, whereas non-judging increased the association between cyberbullying victimization and depression.

CONCLUSIONS

Cybervictimization is associated with NSSI. The mindfulness facet of acting with awareness plays a protector role. Interventions in NSSI and cyberbullying could benefit from these findings.

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.

Which are the best questionnaires to longitudinally evaluate mindfulness skills in personality disorders?

BACKGROUND

Personality disorders (PDs) are severe mental illnesses, characterized by inflexible and enduring response patterns in a broad range of personal and social situations. With the aim of identifying effective and evidence-based interventions, in the last decades we observed a flourishing of the so-called "thirdwave" cognitive-behavioural therapies, where mindfulness appears as relevant factor in promoting individual well-being and treatment response. In this regard, several authors tried to develop new instruments that enable to measure mindfulness skills, such as the Kentucky Inventory of Mindfulness Skills (KIMS), the Five Facet Mindfulness Questionnaire (FFMQ) and the Philadelphia Mindfulness Scale (PHLMS). The aim of this review is to provide new insights about the mindfulness questionnaires currently used in longitudinal studies in PDs by providing a benchmark for future studies evaluating mindfulness changes associated to therapeutic interventions.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search in PubMed was performed. Three reviewers conducted the data extraction. Longitudinal studies on PDs evaluating mindfulness skills through a validated questionnaire were selected. Ten studies met the selection criteria.

RESULTS

The majority of the studies reviewed (N=7) detected an increase in mindfulness skills (4 rated with FFMQ, 2 KIMS, and 1 Philadelphia Mindfulness Scale). Finally, from the selected studies mindfulness changes were also associated with clinical amelioration.

LIMITATIONS

Few studies evaluate male patients and PDs other than borderline personality disorder.

CONCLUSION

Although mindfulness is a complex construct to operationalize, the considered questionnaires emerged as useful instruments for clinicians to detect changes in mindfulness abilities. In particular, currently the FFMQ appears as the most suitable measure.

Effectiveness of Zhong-Yong thinking based dialectical behavior therapy group skills training versus supportive group therapy for lowering suicidal risks in Chinese young adults: A randomized controlled trial with a 6-month follow-up

BACKGROUND

Dialectical behavior therapy (DBT) is a first-line treatment for the prevention of suicide. Zhong-Yong thinking could be viewed as a Chinese way of dialectical thinking, has long been a culturally dictating thinking style in China. To enhance cultural adaptability, we integrated Zhong-Yong thinking into DBT group skills training and examined its efficacy in suicidal prevention compared with a supportive group therapy and a wait-list group in high-risk suicidal Chinese college students.

METHODS

A total of 97 suicidal participants were randomized to either Zhong-Yong thinking based DBT group skills training (DBT_ZYT , n = 33), or supportive group therapy (SGT; n = 32), or wait-list group (WL; n = 32). DBT_ZYT was a 12-week program based on Zhong-Yong thinking instead of dialectical thinking, coaching participants mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Supportive group therapy was a 12-week program aiming at improving interpersonal effectiveness and emotion regulation skills. Outcome measures were assessed at pre- and post-treatment and 6-month follow-up.

RESULTS

At post-treatment measures, the levels of suicidal ideation, hopelessness, psychache symptoms, and general psychopathology had significantly decreased in both intervention groups; at the 6-month follow-up measures, the intervention effects were better maintained in the DBT_ZYT group rather than in the SGT group. Specifically, DBT_ZYT was more effective in relieving participants' long-term obsessive-compulsive, anxiety, hostility, phobic, psychotic, and additional symptoms.

CONCLUSIONS

Zhong-Yong thinking not only could integrate with DBT skills training in Chinese young adult population, but also has special strength in enhancing DBT's efficacy.

Self-harm, Emotion Regulation, and Experiential Avoidance: A Systematic Review

This study aimed to systemically review the literature regarding self-harm, emotion regulation, and experiential avoidance. Articles were identified through systematic searches of several databases using combinations of the phrases "emotion regulation" AND "experiential avoidance" AND "self-harm," or "self-injury," and "BPD" or "Borderline Personality Disorder." Additional searches were conducted inclusive of terms related to experiential avoidance and emotion regulation, as well as other disorders related to self-harm. 17 articles were identified and reviewed. Results tentatively support the role of experiential avoidance in self-harm; some studies described phenomena similar to experiential avoidance without using the term. Poor emotion regulation was often cited as a reason for engagement in self-harm. Several gaps in the literature were identified and discussed.

Acceptance and present-moment awareness in psychiatric disorders: Is mindfulness mood dependent?

The aim of the present study was to determine 1) whether deficits in two mindfulness dimensions (present-centered awareness and acceptance) were present in individuals with different psychiatric conditions and 2) whether co-existing depressive symptoms affected the mindfulness-related capacities in these groups. A total of 246 individuals, both clinical and non-clinical participants, were included in this study. The clinical sample consisted of 162 individuals; of these, 43 had a diagnosis of cocaine dependence while the remaining 119met clinical criteria for eating disorders (n = 43), major depressive disorder in remission (n = 39), and borderline personality disorder (n = 45). A non-clinical (NC) community sample consisting of 76 individuals was included as a control group. All participants completed self-report instruments to assess present-centered awareness, acceptance, and depressive symptoms. Present-centered awareness scores were significantly associated with depressive symptoms but not with the diagnostic group. By contrast, a significant effect of depressive symptoms and diagnostic group was associated with acceptance scores, with all clinical groups presenting significantly lower scores than the NC sample. These findings suggest that the association between psychopathology, mindfulness, and depressive symptoms varies depending on the specific aspect of mindfulness aspect (i.e., awareness or acceptance) evaluated.