A functional analysis of two transdiagnostic, emotion-focused interventions on nonsuicidal self-injury

The Unified Protocol or Dialectical Behaviour Therapy? Considerations for Choosing Between Two Evidence-Based Transdiagnostic Psychotherapies for Complex Patients

The advent of multiple transdiagnostic treatments in recent decades has advanced the field of clinical psychology while also raising questions for clinicians and patients about how to decide between treatments and how to best deliver a chosen treatment. The purpose of this paper is to review two prominent transdiagnostic treatments that target emotion dysregulation: dialectical behaviour therapy and the unified protocol for transdiagnostic treatment for emotional disorders. First, we review the theoretical underpinnings, research support and proposed mechanisms of action for these treatments. Next, we discuss patient and therapist variables that might indicate which treatment is more appropriate for a given patient and discuss decision-making guidelines to help make this determination with an emphasis on complex patients who may present with risk and/or clinical comorbidities. Finally, we discuss areas for future research that can help further ensure we work to match patients to the treatment that is most likely to benefit them.

Dynamic bidirectional relation between state mindfulness and suicidal ideation among female college students: The moderating effect of trait mindfulness

Research has indicated that mindfulness is a protective factor against suicidal ideation. However, the dynamic reciprocal relation between them has been understudied. In this study, 110 female college students with suicidal ideation completed a measure of trait mindfulness and a 28-day diary of suicidal ideation and three-dimensional state mindfulness, including acting with awareness, present-moment attention, and nonjudgmental acceptance. Dynamic structural equation modeling was used to examine the dynamic and bidirectional effects between dimensions of state mindfulness and suicidal ideation and the moderating effect of trait mindfulness. Results showed that suicidal ideation predicted lower levels of present-moment attention the next day. More importantly, there was a dynamic and bidirectional relation between nonjudgmental acceptance and suicidal ideation for people with trait mindfulness higher than the average level (i.e., M + 0.15SD). Our findings suggested that studies and interventions on suicide should pay more attention to specific dimensions of state mindfulness and trait mindfulness.

Toward a synthesis of cognitive behaviour therapy via component analysis of self-regulation

The cognitive behavioural therapies (CBTs) are the choice psychotherapies for many clinicians treating a wide range of adult psychological disorders including various anxieties, mood, substance use, eating, schizophrenia and personality-related. Empirical research in the CBTs is ever increasing, and the accumulating evidence supporting efficacious treatments is substantial and well documented. However, with prolific research comes a seemingly accelerating and worrying trend of purportedly different therapies, and numerous hybrids and combinations of therapies and techniques. For many clinicians this is increasingly confusing and not helpful in clinical practice. This article is a critique of current trends and directions in clinical research, which show signs of limited effectiveness, fragmentation, and obfuscation. An alternative strategy is proposed-examining transdiagnostic therapeutic effects, which appear related to treating pervasive dysregulated emotions, with component analyses of four principal self-regulation components (viz., self-monitoring; functional analysis; identifying values, goals and treatment-plans; and feedback). Such a strategy is likely to lead to a more coherently synthesized and effective CBT.

A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period

BACKGROUND

Although non-suicidal self-injury (NSSI) is known typically to begin in adolescence, longitudinal information is lacking about patterns, predictors, and clinical outcomes of NSSI persistence among emerging adults. The present study was designed to (1) estimate NSSI persistence during the college period, (2) identify risk factors and high-risk students for NSSI persistence patterns, and (3) evaluate the association with future mental disorders and suicidal thoughts and behaviors (STB).

METHODS

Using prospective cohorts from the Leuven College Surveys (n = 5915), part of the World Mental Health International College Student Initiative, web-based surveys assessed mental health and psychosocial problems at college entrance and three annual follow-up assessments.

RESULTS

Approximately one in five (20.4%) students reported lifetime NSSI at college entrance. NSSI persistence was estimated at 56.4%, with 15.6% reporting a high-frequency repetitive pattern (≥five times yearly). Many hypothesized risk factors were associated with repetitive NSSI persistence, with the most potent effects observed for pre-college NSSI characteristics. Multivariate models suggest that an intervention focusing on the 10-20% at the highest predicted risk could effectively reach 34.9-56.7% of students with high-frequency repetitive NSSI persistence (PPV = 81.8-93.4, AUC = 0.88-0.91). Repetitive NSSI persistence during the first two college years predicted 12-month mental disorders, role impairment, and STB during the third college year, including suicide attempts.

CONCLUSIONS

Most emerging adults with a history of NSSI report persistent self-injury during their college years. Web-based screening may be a promising approach for detecting students at risk for a highly persistent NSSI pattern characterized by subsequent adverse outcomes.

Effects of emotion, emotional tolerance, and emotional processing on reasoning

Emotion plays a significant role in our reasoning even without awareness, perhaps especially for individuals who have difficulties tolerating strong, negative emotions. Opportunity for reflection may help such individuals decide when emotions should influence reasoning. Two studies attempted to clarify the relationships among reasoning, emotions, and emotion tolerance (measured with the Affect Intolerance Scale). The first examined the effect of affect intolerance on a reasoning task. Participants were asked to determine whether conclusions logically followed from both emotional and neutral if-then statements. Emotion had a small effect on performance on the reasoning task, unmoderated by affect intolerance. The second study examined whether reflection on emotional responses impacts performance on the same reasoning task. Participants asked to reflect on their emotions performed more poorly on the reasoning task than participants asked to reflect on the task's cognitive aspects. People who endorse greater affect tolerance performed better in the cognitive reflection condition than the emotional reflection condition. People with less tolerance performed the same in both conditions. Overall, these studies support previous findings that emotion can negatively impact performance on reasoning tasks but suggest a more complex relationship for affect intolerance.

Harsh parenting and adolescent non-suicidal self-injury: A moderated mediation model of alienation and cognitive reappraisal

OBJECTIVE

Harsh parenting has been shown to be associated with non-suicidal self-injury (NSSI) in adolescents. Based on the integrated theoretical model of the development of NSSI and the cognitive-emotional model of NSSI, we proposed a moderated mediation model to investigate "how" and "when" harsh parenting is associated with adolescent NSSI. Specifically, we tested whether feelings of alienation mediated the association between harsh parenting and NSSI, and whether this indirect effect was weakened by cognitive reappraisal as an adaptive emotion regulation strategy.

METHODS

A total of 1638 Chinese adolescents (54.7 % girls; ages 12-19 years) completed self-report questionnaires in their classrooms. The questionnaires assessed harsh parenting, feelings of alienation, cognitive reappraisal skills, and incidents of NSSI.

RESULTS

Path analyses showed that harsh parenting positively predicted NSSI, and alienation mediated this association. Both the direct effect of harsh parenting on NSSI and the indirect effect through alienation were moderated by cognitive reappraisal. Specifically, cognitive reappraisal skills weakened the direct and indirect associations between harsh parenting and NSSI.

CONCLUSIONS

Adolescents may benefit from interventions that decrease feelings of alienation and increase cognitive reappraisal strategies to reduce the risk of NSSI in the context of harsh parenting.

Enhancing emotion regulation

BACKGROUND

Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives: This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER.

METHOD

A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation.

RESULTS

In eight studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods from pre- to post-treatment was large (g = 0.82).

CONCLUSIONS

Both affect-focused and structured skill training are associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must consider how patients' cultural backgrounds inform display rules, as well as what might be considered adaptive or maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.

An investigation of self-injury in female adolescents: a qualitative study

This study aimed to investigate the phenomenon of self-injury among female adolescents. The research was qualitative, and the sampling method was purposive non-random; the sample size was 20 Iranian girl adolescents aged 13-15 years who had experienced non-suicidal self-injury. Data were collected through semi-structured interviews. The data analysis process was performed during three coding steps (open, axial, selective), through which the basic codes and categories were identified. Study results indicate that the main factors in adolescents' self-injury were individual or psychological (thoughts, emotions, and behaviors) and social (peers, family, communication with different gender, communication with others, media/cyberspace, school, and economic). In the former, the role of emotions was remarkable, while in the latter, the family played a key role. Further, results revealed that communication within the family was an important motivating and sustentative factor in adolescents' self-injury. The results can help counselors in working with adolescents who self-injure; results can also be used in the development and implementation of treatment plans.

Peer Victimization and Adolescent Non-Suicidal Self-Injury: The Mediating Role of Alienation and Moderating Role of Mindfulness

Peer victimization and non-suicidal self-injury (NSSI) are two major public health problems, with the former being associated with outward attack and the latter characterizing inward attack. Peer victimization has been shown to be associated with adolescents' NSSI. However, less is known about the mechanism underlying the association. Based on the experiential avoidance model of NSSI, this study tested whether the sense of alienation mediated the association between peer victimization and NSSI, and whether this process was weakened by mindfulness. A total of 1,574 Chinese adolescents (51.1% girls; ages 12-16 years) completed questionnaires concerning NSSI, peer victimization, alienation, and mindfulness. Regression-based analyses indicated that peer victimization predicted adolescents' NSSI through the indirect effect of alienation, and mindfulness weakened this indirect effect. These findings suggest that victimized adolescents may injure themselves as an emotion regulation strategy. The results highlight the importance to implement programs aimed to improve the school climate to reduce the risk of adolescent NSSI. Furthermore, we underscore the need to include emotion-regulation training (e.g., mindful practice) into bully intervention programs to prevent NSSI.

Nonsuicidal self-injury in undergraduate students: a cross-sectional study and association with suicidal behavior

The objective of this study was to investigate nonsuicidal self-injury (NSSI) in graduates and correlate NSSI with sociodemographic profile, suicidal behavior, and prior mental health disorders. The study is part of a larger survey investigating sociodemographic profile, quality of life and mental health in undergraduates from one of Brazil´s largest universities. A bespoke questionnaire was devised about NSSI based on the DSM5 diagnostic criteria. The data were analyzed using the statistical analysis package SPSS. A total of 6.906 university students took part in the study. Regarding NSSI, 17.8% of students reported at least one episode in their lifetime, and 35% reported age at NSSI onset of 14-16 years. Self-injurious behavior was associated with female gender, self-reported black skin color, dissatisfaction with the chosen course, history of bullying and prior mental disorder. There was a ten times greater risk of suicidal behavior among self-injurers and this risk was higher still for recurrent NSSI.

Mindfulness mediates the relationship between positive parenting and aggression, depression, and suicidal ideation: A longitudinal study in middle school students

Previous research has indicated that parenting factors affect the risk of maladaptive psychological outcomes (e.g., aggression, depression, or suicidal ideation), and that positive parenting is a prospective risk factor for maladaptive psychological outcomes. However, the mechanisms underlying the relationships between positive parenting, mindfulness, and maladaptive psychological outcomes remain unknown, as do the processes that mediate the effect of positive parenting on maladaptive psychological outcomes in adolescents. The objective of the present study was to investigate the longitudinal relationship between positive parenting, mindfulness, and maladaptive psychological outcomes in middle school students, as well as the mediating effect of mindfulness in the relationships between positive parenting and depression, aggression, and suicidal ideation. In this study, 386 middle school children (aged 12–16) were tested three times over a period of 6 months. Positive parenting was assessed at Time 1, mindfulness at Time 2, and depression, aggression, and suicidal ideation at Time 3. Using structural equation modeling, positive parenting was revealed to be longitudinally associated with mindfulness and negatively associated with maladaptive psychological outcomes. More crucially, mindfulness mediated the relationship between positive parenting and maladaptive psychological outcomes. This research provides important insights into how to effectively decrease adolescent maladaptive psychological outcomes and highlights the importance of teaching mindfulness to youths.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Skill Acquisition During Transdiagnostic Treatment With the Unified Protocol

The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is an emotion-focused, cognitive-behavioral intervention developed to address the full range of anxiety, depressive, and related disorders. The UP consists of core therapeutic skills that, though unique in focus, are each designed to promote an approach-oriented stance toward emotional experiences. The goal of the present investigation was to characterize changes in these skills for patients that received a course of treatment with the UP, as well as to examine associations between skills and symptoms changes. Patients with principal anxiety disorders, assigned to receive treatment with the UP (N = 88) as part of a randomized controlled trial, were included in this study. They completed validated self-report measures of UP skills (Understanding Emotions, Mindful Emotion Awareness, Cognitive Flexibility, Countering Emotional Behaviors, and Interoceptive Awareness and Tolerance), as well as clinician-rated measures of psychological symptoms. Skill measures improved significantly over the course of 12 to 16 UP treatment sessions and changes in these skills measures were associated with improvements in anxiety symptoms. Determining whether improvement on all the skills learned during a course of treatment with UP is associated with symptom remission is critical to establishing the most streamlined and efficient interventions that may ultimately be best suited to widespread dissemination.

Variability in the Functions of Nonsuicidal Self-Injury: Evidence From Three Real-Time Monitoring Studies

Despite functional models of nonsuicidal self-injury (NSSI) helping to explain why people engage in this perplexing behavior, we still lack an understanding of some of the key properties of NSSI functions. Here, we address three unanswered questions about NSSI functions: how much do distinct NSSI functions (1) vary between people over time, (2) vary within people over time, and (3) simultaneously co-occur over time? Data were drawn from three ecological momentary assessment (EMA) studies of self-injurious adult psychiatric outpatients (n = 7), community-based adolescents (n = 15), and community-based adults (n = 9). Across the three studies, there was a total of 271 NSSI episodes (all with corresponding functions captured by EMA). The vast majority (27 of 31; 87%) of participants exhibited unique patterns of NSSI functions during the monitoring periods, indicating high variability between people. The vast majority (26 of 31; 84%) of participants also showed changes in NSSI functions over time, indicating high variability within people. Although it was most common for only one function to be reported for a given NSSI episode, participants endorsed more than one function for 22% to 43% of NSSI episodes, indicating that different functions did simultaneously co-occur. These results underscore that reinforcement processes for NSSI differ from person-to-person, and are both time-varying and multifaceted, which has implications for personalized assessment and treatment of this clinical phenomenon.

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.

Big Five Personality Clusters in Relation to Nonsuicidal Self-Injury

Nonsuicidal self-injury (NSSI) is a complex behavior that serves many functions and may be motivated by several factors. Although previously limited to the context of personality disorders, consideration of how general personality traits might be related to NSSI warrants examination. Our aims were to investigate whether clusters based upon the Big Five personality traits exist among people who have engaged in NSSI, and explore systematic differences with regard to gender, age, key indicators of NSSI severity, functions of NSSI, emotional avoidance, alexithymia, psychological distress, and emotion regulation strategies. A sample of 236 university students (83% female, M age = 21.59, SD = 5.43) who had engaged in NSSI completed an anonymous online questionnaire. Cluster analysis yielded three subgroups who were characterized by tendencies for resilience, dysregulation, and disagreeableness. Resilient and dyregulated profiles fell within opposite ends of a continuum with regard to severity of NSSI, psychological distress and alexithymia, and adaptive vs less adaptive emotion regulation strategies. Dysregulated characteristics were also associated with affect regulation and self-punishment functions of NSSI. Disagreeable characteristics were associated with high alexithymia and psychological distress. Implications of these findings for theory and tailored treatment approaches to NSSI are discussed.

Predicting self-injurious thoughts in daily life using ambulatory assessment of state cognition

Self-injurious thoughts (SITs) fluctuate considerably from moment to moment. As such, "static" and temporally stable predictors (e.g., demographic variables, prior history) are suboptimal in predicting imminent SITs. This concern is particularly true for "online" cognitive abilities, which are important for understanding SITs, but are typically measured using tests selected for temporal stability. Advances in ambulatory assessments (i.e., real-time assessment in a naturalistic environment) allow for measuring cognition with improved temporal resolution. The present study measured relationships between "state" cognitive performance, measured using an ambulatory-based Trail Making Test, and SITs. Self-reported state hope and social connectedness was also measured. Data were collected using a specially designed mobile application (administered 4x/week up to 28 days) in substance use inpatients (N = 99). Consistent with prior literature, state hope and social connectedness was significantly associated with state SITs. Importantly, poorer state cognitive performance also significantly predicted state SITs, independent of hallmark static and state self-report risk variables. These findings highlight the potential importance of "online" cognition to predict SITs. Ambulatory recording reflects an efficient, sensitive, and ecological valid methodology for evaluating subjective and objectives predictors of imminent SITs.

Integrating theory-based and data-driven methods to case conceptualization: A functional analysis approach with ecological momentary assessment

Objective Ecological momentary assessment (EMA) and network analysis are promising empirical developments for psychotherapy research and practice, but they lack a therapeutic rationale that could guide case conceptualization and treatment planning. We developed an assessment strategy that aims to assess functional analysis with EMA. Method: The assessment strategy was applied to a series of three N-of-1 assessments in a proof-of-concept study. After selecting a personalized set of items, EMA was implemented with three measurement time points per day for a period of 30 days. The participants evaluated feasibility and acceptance. Practicing psychotherapists discussed clinical implications in a focus group. Results: The implementation of the assessment strategy seemed feasible and accepted; participants did not report any side effects. Principal component and network analyses indicated interpretable components (e.g., participant 1: hopelessness, procrastination, coping, avoidance). The focus group pointed out potentials (e.g., efficient profit of the waiting time, empowering patients) and challenges (e.g., prioritize and interpret all the information). Conclusion: The presented assessment strategy may enhance the scientific quality of case conceptualization empowering therapists' decision-making regarding treatment planning. At the same time, it is a concrete demonstration of the challenges that need to be addressed in future research.

An exploratory mixed methods approach to implicit and explicit identification with non-suicidal self-injury

BACKGROUND AND OBJECTIVES

Identification with non-suicidal self-injury (NSSI) is uniquely related to NSSI behavior and predicts future NSSI. This exploratory, mixed methods study used implicit and explicit approaches to further understanding of NSSI identity.

METHODS

Participants included 15 treatment-seeking adults (60% female, 87% Caucasian) with lifetime NSSI. Participant age ranged from 19 to 38 years (M = 25.33, SD = 6.10). Implicit tasks were completed at two time points in a test-retest design, followed by a qualitative interview.

RESULTS

Qualitative data suggest that explicit NSSI identity is relevant to some individuals with NSSI history. Mixed methods analyses indicate that individuals who explicitly identify with NSSI have stronger implicit NSSI identities than those who do not, and report more methods of NSSI on average.

LIMITATIONS

Results are novel, although exploratory in nature due to the sample size, and may not be generalizable to non-clinical samples or individuals currently engaging in NSSI.

CONCLUSIONS

Individuals with stronger explicit identity evidence higher implicit identity scores, suggesting a potential higher risk profile for future NSSI. This study offers further support for the value of including both implicit and explicit assessment of NSSI identity in risk assessment.

Treating depressive disorders with the Unified Protocol: A preliminary randomized evaluation

OBJECTIVES

This study aims to examine the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) for individuals diagnosed with a depressive disorder.

METHOD

Participants included 44 adults who met criteria for major depressive disorder, persistent depressive disorder, or another specified depressive disorder according to the Anxiety Disorder Interview Schedule (ADIS). These individuals represent a subset of patients from a larger clinical trial comparing the UP to single-disorder protocols (SDPs) for discrete anxiety disorders and a waitlist control (WLC) condition (Barlow et al., 2017); inclusion criteria for the parent study required participants to have a principal anxiety disorder.

RESULTS

Significant reductions in depressive symptoms were observed within the UP condition across clinician-rated and self-report measures of depression from baseline to post-treatment, as well as to the 12-month follow-up assessment. Compared to the WLC group, individuals in the UP condition demonstrated significantly lower levels on our continuous, clinician-rated measure of depressive symptoms at post-treatment. There were no differences between the UP and SDP conditions on depressive symptoms at post-treatment or at the 12-month follow-up timepoint.

CONCLUSIONS

In this exploratory set of analyses, the UP evidenced efficacy for reduction of depressive symptoms, adding to the growing support for its utility in treating depression.

Implementing an evidence-based psychological intervention for suicidal thoughts and behaviors on an inpatient unit: Process, challenges, and initial findings

OBJECTIVE

Barriers to implementing evidence-based psychological treatments for suicidal thoughts and behaviors in busy hospital settings exist. Transdiagnostic interventions may serve to facilitate training in evidence-based treatment and more efficiently treat individuals with multiple psychiatric comorbidities. We describe the rationale for, process of, and initial data from implementing the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) on an inpatient unit for adults with suicidal thoughts and behaviors and affective disorders.

METHOD

We analyzed clinical intake and outcome data from a subsample of patients admitted during the six months before and six months after UP implementation (n = 133 and n = 61, respectively), and available acceptability and fidelity data from the month following UP implementation.

RESULTS

Patients improved significantly over the course of inpatient treatment before and after UP implementation. Effects for depression, suicidal ideation, anxiety, and emotion regulation were similar before and after UP implementation. Patients generally reported high acceptability of the UP and clinician fidelity to the protocol was variable during the month following UP implementation.

CONCLUSIONS

The UP may be a promising evidence-based intervention for inpatient settings that treat individuals with suicidal thoughts and behaviors. Well-controlled, randomized trials are needed to determine efficacy, particularly regarding suicidal behavior after discharge.

Improved quality of life and reduced depressive symptoms in medical students after a single-session intervention

OBJECTIVE

Anxiety and depression are prevalent among medical students. Brazilian medical students have higher levels of depression and lower quality of life than their U.S. counterparts, and no preventive intervention exists for this risk group in Brazil. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), a cognitive-behavioral treatment protocol for neuroticism, was recently adapted into a single-session, preventive intervention. This study tested the impact of this protocol on psychiatric symptoms and quality of life in Brazilian medical students.

METHODS

In this open trial, the intervention protocol was translated and adapted to Brazilian Portuguese. Medical students over 18 years of age without psychotic symptoms, severe depressive episodes, or acute psychiatric risk were included, undergoing a psychiatric clinical interview (Mini-International Neuropsychiatric Interview [MINI]) and evaluation at baseline and at 7 and 30 days after a single-session UP that included experimental avoidance, quality of life, self-esteem, empathy, and anxiety symptom scales. A new evaluation was performed 90 days after the intervention.

RESULTS

Sixty-two students participated. Ninety days after the intervention, there were significant reductions in the number of students who met the criteria for social anxiety disorder (p = 0.013) or panic disorder (p = 0.001). There were also significant improvements in depressive symptoms (Beck Depression Inventory, p < 0.001) and quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire, p < 0.001).

CONCLUSION

UP improved anxiety and depressive symptoms in medical students. The single-session group format could reduce costs and facilitate application. Future placebo-controlled studies are necessary to confirm these findings.

Cognitive-Behavioral Therapy for Anxiety in Parkinson's Disease

Parkinson's disease (PD) is characterized by motor symptoms, but nonmotor symptoms also significantly impair daily functioning and reduce quality of life. Anxiety is prevalent and debilitating in PD, but remains understudied and undertreated. Much affective research in PD focuses on depression rather than anxiety, and as such, there are no evidence-based treatments for anxiety in this population. Cognitive-behavioral therapy (CBT) has shown promise for treating depression in PD and may be efficacious for anxiety. This exploratory study implemented a multiple-baseline single-case experimental design to evaluate the utility and feasibility of CBT for individuals with PD who also met criteria for a DSM-5 anxiety disorder (n = 9). Participants were randomized to a 2-, 4-, or 6-week baseline phase, followed by 12 CBT sessions, and two post treatment assessments (immediately post treatment and 6-week follow-up). Multiple outcome measures of anxiety and depression were administered weekly during baseline and intervention. Weekly CBT sessions were conducted in-person (n = 5) or via secure videoconferencing (n = 4). At post treatment, seven of the nine participants showed significant reductions in anxiety and/or depression, with changes functionally related to treatment and most improvements maintained at 6-week follow-up. Effects of CBT on secondary outcomes varied across participants, with preliminary evidence for reduction in fear of falling. Adherence and retention were high, as were treatment satisfaction and acceptability. The findings of this pilot study provide preliminary evidence for the utility of CBT as a feasible treatment for anxiety and comorbid depressive symptoms in PD and highlight the potential of telehealth interventions for mood in this population.

Use of Ecological Momentary Assessment (EMA) in Non-Suicidal Self-Injury (NSSI): A systematic review

Conceptualization and assessment of non-suicidal self-injury (NSSI) has evolved substantially in recent years. In both cross-sectional and longitudinal studies, NSSI and its related variables have traditionally been assessed retrospectively, leading to less precise studies of the mechanisms involved in the maintenance, cessation, or aggravation of this behavior. Ecological momentary assessment (EMA) enables real-time collection of patient states, which can be very useful in the study of the mechanisms implied in this behavior. This systematic review aims to elucidate the current status of EMA use in NSSI investigation. An exhaustive search in PubMed and PsycINFO was conducted up to September 2017. All papers included were focused on the study of NSSI using EMA. Studies with methodological diversity were included, which were afterwards organized according to main topic of studies. There were no ineligibility criteria based on age or diagnosis. Twenty-three papers were studied, the majority of which are short-term studies focused on the study of affect dynamics and the emotion-regulation function of NSSI. Implications of these results and recommendations for future research are discussed.

Work Stress and Depressive Symptoms in Fishermen With a Smoking Habit: A Mediator Role of Nicotine Dependence and Possible Moderator Role of Expressive Suppression and Cognitive Reappraisal

This study examined pathways of influence between work stress, depressive symptoms, nicotine dependence, expressive suppression, and cognitive reappraisal in fishermen with smoking habits in Qionghai, Hainan province, China (N = 1068). These fishermen responded to multiple assessments a week before leaving on a deep-sea fishing trip, including a Mental Stressor Investigation Questionnaire (MSIQ), the Center for Epidemiological Studies Depression Scale (CES-D), the Russell Reason for Smoking Questionnaire (RRSQ), and an Emotion Regulation Questionnaire (ERQ). Structural equation modeling (SEM) analyses of the collected data in Mplus 7 showed that work stress and nicotine dependence were independent predictors of depressive symptoms. The relationship between work stress and depressive symptoms was found to be partially mediated by nicotine dependence and be moderated by cognitive reappraisal. The evidence suggests it advantageous to examine the need of work stress, nicotine dependence, and cognitive reappraisal when attempting to understand depressive symptoms in fishermen with a smoking habit. These findings suggest that improving nicotine dependence through work stress management and training in cognitive reappraisal could be utilized as effective modalities for improving depressive symptoms.

Emotion Dysregulation in the Structure of Self-Injurious Behavior

We present the results of the research of the link between emotion regulation and self-injurious behavior. The sample consisted of 706 respondents aged 14—35 (467 female). Methods: Emotion Dysregulation Questionnaire (Polskaya, Razvaliaeva, 2017), Reasons for Self-Injury Scale (Polskaya, 2017), Coping Behavior Strategies Questionnaire (Vasserman et al., 2008), Psychological Mindedness Scale (Novikova, Kornilova, 2014), Positive and Negative Affect Scale (Osin, 2012). Results: we found out that self-injury is more frequent in females, self-injury risk is most severe at 14—21 years. Significant relationships were yielded for self-injurious behavior, emotion dysregulation, hindered awareness and access to emotions, and coping strategies — confrontation, avoidance, self-control, and responsibility. Regression analysis showed that avoidance as a strategy of emotion dysregulation mediates the influence of negative affect on self-injurious behavior; another form of emotion dysregulation — rumination — predicts the increase of negative and the decrease of positive affect. Conclusions: emotion dysregulation underlies the cycle of negative affect aggravation that leads to self-injury. Adolescence and youth are the most dangerous ages when self-injury is used for negative affect regulation.

Development of a Single-Session, Transdiagnostic Preventive Intervention for Young Adults at Risk for Emotional Disorders

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.