Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy: preliminary results

Early remission of deliberate self-harm predicts emotion regulation capacity in adulthood: 12.4 years follow-up of a randomized controlled trial of adolescents with repeated self-harm and borderline features

Emotion regulation capacity, critical for adult functioning and mental health, develops strongly during adolescence in healthy individuals. Deficits in emotion regulation is often referred to as emotion dysregulation [ED] and is associated with various mental health problems, including repeated deliberate self-harm [DSH] which peaks in adolescence. Dialectical Behaviour Therapy for adolescents [DBT-A] systematically targets ED through strategies such as changing coping behaviours and has previously been shown to effectively induce DSH remission in adolescents. However, whether such remission is associated with improved emotion regulation capacity in adulthood, and whether this effect is mediated by changes in use of coping strategies has not been previously studied. Prospective long-term follow-up study of an RCT comparing DBT-A with enhanced usual care [EUC] for adolescents presenting to community child and adolescent psychiatric outpatient clinics with borderline personality features and repeated self-harm. Assessments included both structured interviews and self-report at baseline and 1.6, 3.1 and 12.4 years follow-up. In the final follow-up, adult ED was measured and data were collected for 61 (80%) of the original 77 participants. DSH remission was assessed at 1.6 years follow-up, and use of coping strategies at 3.1 and 12.4 years follow-ups. A mediation analysis was conducted within a causal inference framework. Both treatment groups increased their use of functional coping skills from adolescence to adulthood, while only DBT-A was associated with decreases in dysfunctional coping. There was a direct effect of DSH remission 1 year after treatment on adult ED, particularly for participants who did not receive DBT-A. There was a negative association between reductions in dysfunctional coping and adult ED, however this did not mediate the effect of DSH remission. This is the first study to report that early DSH remission in adolescence predicted lower ED in adulthood. These results highlight the importance of early DSH remission and provides new insight into the long-term relationship between DSH and ED. Clinical trial registration information: "Treatment for Adolescents with Deliberate Self-harm"; http://ClinicalTrials.gov/;NCT00675129.

Feasibility, Acceptability, and Potential Efficacy of a Self-Guided Internet-Delivered Dialectical Behavior Therapy Intervention for Substance Use Disorders: Randomized Controlled Trial

BACKGROUND

People with alcohol and substance use disorders (SUDs) often have underlying difficulties in regulating emotions. Although dialectical behavioral therapy is effective for SUDs, it is often difficult to access. Self-guided, internet-delivered dialectical behavioral therapy (iDBT) allows for expanded availability, but few studies have rigorously evaluated it in individuals with SUDs.

OBJECTIVE

This study examines the feasibility, acceptability, and potential efficacy of an iDBT intervention in treatment-seeking adults with SUDs. We hypothesized that iDBT would be feasible, credible, acceptable, and engaging to people with SUDs. We also hypothesized that the immediate versus delayed iDBT group would show comparatively greater improvements and that both groups would show significant improvements over time.

METHODS

A 12-week, single-blinded, parallel-arm, randomized controlled trial was implemented, with assessments at baseline and at 4 (acute), 8, and 12 weeks (follow-up). A total of 72 community adults aged 18 to 64 years were randomized. The immediate group (n=38) received access to iDBT at baseline, and the delayed group (n=34) received access after 4 weeks. The intervention (Pocket Skills 2.0) was a self-guided iDBT via a website, with immediate access to all content, additional text and email reminders, and additional support meetings as requested. Our primary outcome was substance dependence, with secondary outcomes pertaining to feasibility, clinical outcomes, functional disability, and emotion dysregulation, among other measures. All outcomes were assessed using self-report questionnaires.

RESULTS

iDBT was perceived as a credible and acceptable treatment. In terms of feasibility, 94% (68/72) of the participants started iDBT, 13% (9/68) were early dropouts, 35% (24/68) used it for the recommended 8 days in the first month, and 50% (34/68) were still active 4 weeks later. On average, the participants used iDBT for 2 hours and 24 minutes across 10 separate days. In the acute period, no greater benefit was found for the immediate group on substance dependence, although we did find lower depression (b=-2.46; P=.02) and anxiety (b=-2.22; P=.02). At follow-up, there were greater benefits in terms of reduced alcohol (b=-2.00; P=.02) and nonalcoholic substance (b=-3.74; P=.01) consumption in the immediate access group. Both groups demonstrated improvements in substance dependence in the acute (b=-1.73; P<.001) and follow-up period (b=-2.09; P<.001). At follow-up, both groups reported reduced depression, anxiety, suicidal behaviors, emotional dysregulation, and functional disability.

CONCLUSIONS

iDBT is a feasible and acceptable intervention for patients with SUDs, although methods for improving engagement are warranted. Although results did not support efficacy for the primary outcome at 4 weeks, findings support reductions in substance dependence and other mental health concerns at 12 weeks. Notwithstanding the limitations of this study, the results suggest the potential value of iDBT in the treatment of SUDs and other mental health conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05094440; https://clinicaltrials.gov/show/NCT05094440.

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.

Just try it: Preliminary results of a six-month therapy for borderline personality disorder

Borderline Personality Disorder (BPD) is labeled as a personality disorder with impulsivity issues regarding relationships, risky behavior, and emotional dysregulation. This personality disorder is still considered to be hard-to-treat condition even though responses to treatment have improved significantly. In this field, Dialectical Behavioral Therapy is recognized as one of the most efficient therapeutical approaches, and some versions adapted from this gold-standard treatment proved their effectiveness in clinical settings. We tested the 6-month cognitive behavioral therapy (CBT) protocol ECCCLORE, composed of three modules, respectively, working on emotional regulation, distress tolerance, and relationships-in a French context to compare its effectiveness to Treatment As Usual. We recruited 56 patients with a BPD diagnosis in a day-care unit, 34 receiving ECCCLORE and 22 receiving TAU. We assessed BPD traits, impulsivity, aggressiveness, suicidal risk, and hopelessness. Our results revealed the effectiveness of the 6-month ECCCLORE protocol to decrease BPD symptoms and associated clinical dimensions. We also noted the persistence of its effect after a 1-year follow-up. Shortened CBT treatment protocols tend to prove their efficiency for symptom reduction in BPD. Further research is needed to replicate these results.

Mindfulness training for borderline personality disorder: A systematic review of contemporary literature

Mindfulness is a component of several psychotherapies. Nonetheless, its effectiveness in borderline personality disorder (BPD) management remains obscure. This systematic review examined the effect of mindfulness training in BPD patients. Cochrane Central Register of Controlled Trials, CAB Abstracts, Embase, MEDLINE and APA PsycInfo were searched until 30 June 2021. Five trials with 294 participants were included. Improvements were reported in participants' levels of impulsivity, in their emotion dysregulation patterns, in their attention skills and in their mindfulness-related capacities including decentering and nonjudging. The findings suggest that mindfulness training may be an effective tool for alleviating certain aspects of BPD symptomatology. More research is needed before definitive conclusions can be reached about the effectiveness of mindfulness training in the treatment of BPD patients, and this remains to be elucidated in larger structured clinical trials, with longer follow-ups.

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.

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.

Dialectical behaviour therapy skills training for the treatment of addictive behaviours among individuals with alcohol use disorder: the effect of emotion regulation and experiential avoidance

BACKGROUNDS

Dialectical behavior therapy skills training (DBT-ST) is an effective treatment for alcohol use disorder (AUD). AUD frequently co-occurs with other addictive behaviors.

OBJECTIVE

s: These secondary analyses of prior studies on the effectiveness of a 3-month DBT-ST program for AUD investigated pre- post-treatment changes in the severity of concurrent addictive behaviors. The study hypothesized that emotion regulation and experiential avoidance should be the key therapeutic mechanisms involved in the treatment of addictive behaviors.

METHODS

The research included 186 individuals (110 males; 76 females) with a primary diagnosis of AUD. Mediational models were performed considering shorter PROMIS questionnaire subscales (i.e., gambling, sex, shopping, food binging, and starvation) as dependent variables. The difficulties in emotion regulation scale and acceptance and action questionnaire-II total scores were independent and mediator variables, respectively.

RESULTS

Clinical variables significantly improved during the treatment, independent of baseline levels. Changes in emotion regulation showed significant total effects on improvements in addictive behaviors. Significant indirect effects of changes in experiential avoidance were detected considering compulsive buying and dysfunctional eating behaviors.

CONCLUSION

The DBT-ST was a feasible treatment for several addictive behaviors frequently reported by individuals with AUD. The improvements in emotion regulation and experiential avoidance were relevant therapeutic mechanisms involved in the treatment of these conditions. Future controlled trials and follow-up studies are recommended to support the efficacy of DBT-ST as a stand-alone intervention for the treatment of different classes of addictive behaviors.

The therapeutic role of emotion regulation and coping strategies during a stand-alone DBT Skills training program for alcohol use disorder and concurrent substance use disorders

Clinical trials on Dialectical Behavior Therapy Skills Training (DBT-ST) as a stand-alone intervention for alcohol use disorder (AUD) showed promising outcomes. Improvements in difficulties with emotion regulation (DER) played a mediating role on abstinence maintenance. However, the effect of DER, together with specific coping strategies, have not been considered yet in the treatment of clinical features associated to AUD and concurrent substance use disorders (CO-SUDs). The current study aims at investigating changes in the number of consecutive days of abstinence (CDA), severity of AUD and CO-SUDs (Shorter PROMIS Questionnaire; SPQ alcohol, prescription, illicit drugs subscale), DER (Difficulties in Emotion Regulation Scale; DERS) and coping strategies (DBT Way of Coping Checklist; DBT-WCCL) during a 3-month DBT-ST program for the treatment of AUD and CO-SUDs. Furthermore, four independent multiple parallel mediational models were estimated considering scores of CDA/SPQ, DERS and DBT-WCCL dimensions as dependent, independent and mediators variables respectively. One-hundred eight individuals with a primary diagnosis of AUD were consecutively admitted. The results showed significant and moderate to large improvements in CDA, severity of AUD, CO-SUDs and DER. The analyses detected significant improvements in the use of DBT Skills. The changes in DER predicted decreases in SPQ scores. The changes in DBT-WCCL scores were mediators of the previous relationships, considering SPQ alcohol and prescription drugs subscales. These findings support the implementation of DBT-ST as a stand-alone intervention for the treatment of AUD and CO-SUDs. DER together with coping strategies are relevant therapeutic mechanisms in the treatment of clinical features related to SUDs.

Relations of mindfulness facets with psychological symptoms among individuals with a diagnosis of obsessive-compulsive disorder, major depressive disorder, or borderline personality disorder

OBJECTIVES

To explore differences in mindfulness facets among patients with a diagnosis of either obsessive-compulsive disorder (OCD), major depressive disorder (MDD), or borderline personality disorder (BPD), and healthy controls (HC), and their associations with clinical features.

DESIGN AND METHOD

One hundred and fifty-three patients and 50 HC underwent a clinical assessment including measures of mindfulness (Five Facets Mindfulness Questionnaire - FFMQ), psychopathological symptoms (Symptom Check List-90-R), dissociation (Dissociative Experience Scale), alexithymia (Alexithymia Scale 20), and depression (Beck Depression Inventory-II). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were performed to assess differences in mindfulness scores and their associations with clinical features.

RESULTS

The three diagnostic groups scored lower on all mindfulness facets (apart from FFMQobserving) compared to the HC group. OCD group had a significant higher FFMQ total score (FFMQ-TS) and FFMQacting with awareness compared to the BPD group, and scored higher on FFMQdescribing compared to BPD and MDD groups. The scores in non-judging facet were significantly lower in all the three diagnostic groups compared to the HC group. Interestingly, higher FFMQ-TS was inversely related to all psychological measures, regardless of diagnostic group.

CONCLUSIONS

Deficits in mindfulness skills were present in all diagnostic groups. Furthermore, we found disease-specific relationships between some mindfulness facets and specific psychological variables. Clinical implications are discussed.

PRACTITIONER POINTS

The study showed deficits in mindfulness scores in all diagnostic groups compared to a healthy control group. Overall, mindfulness construct has a significantly negative association with indexes of global distress, dissociative symptoms, alexithymia, and depression. Mindfulness-based interventions in clinical settings should take into account different patterns of mindfulness skills and their impact on disease-specific maladaptive cognitive strategies or symptomatology.

Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment: Findings Based on an Open Trial

BACKGROUND

Dialectical behavior therapy (DBT) has demonstrated efficacy in treating disorders such as alcohol dependence that are characterized by emotional dysregulation. Preliminary evidence has revealed the feasibility of DBT skills training (ST) as a stand-alone treatment for such disorders. Although emotional dysregulation plays a significant role in alcohol dependence, there are no previous reports of using DBT-ST to treat it.

OBJECTIVES

The aim of this study was to evaluate the duration of abstinence and changes in emotional regulation in a 3-month DBT-ST program for alcohol-dependent patients and to look for relations between abstinence and emotional regulation.

METHODS

We administered the Difficulties in Emotion Regulation Scale (DERS) and used urine toxicology screening to monitor alcohol/substance intake among the 244 subjects admitted to the program.

RESULTS

Among the 157 patients who completed the treatment, 73.2% were abstinent at the end of the program, and their emotional regulation improved. Improvement was independent of the initial severity of both alcohol use and emotional dysregulation. For substance use outcomes, we found a partial mediation role of improved emotional regulation.

CONCLUSIONS

This is the first open trial to show improved alcohol-related behavior and emotional regulation in alcohol-dependent patients treated with DBT-ST and to posit a partial but significant relation between improved emotional regulation and alcohol use outcomes. In the treatment of alcohol dependence, emotional regulation may be a relevant factor for therapists to consider.

Self-Compassion Mediates the Relationship Between Mindfulness and Borderline Personality Disorder Symptoms

Individuals suffering from borderline personality disorder (BPD) experience difficulties with mindfulness. How mindfulness influences BPD symptoms, however, is still unknown. We hypothesized that the relationship between mindfulness and BPD symptoms would be mediated by self-compassion. In study 1, we recruited 29 individuals with BPD and 30 group-matched healthy controls. In study 2, we complemented our results with findings from a larger, nonclinical sample of 89 participants that were recruited during an open-house event at the local university. All participants completed questionnaires assessing self-compassion, mindfulness, BPD symptom severity, and emotion dysregulation. In both studies, self-compassion mediated the relationship between mindfulness and BPD symptom severity as well as between mindfulness and emotion dysregulation. Self-compassion seems to be one psychological process that could explain the relationship between mindfulness and BPD symptoms. One promising approach in therapy could be to target self-compassion more directly during mindfulness trainings and interventions.

Mindfulness-based interventions and their effects on emotional clarity: A systematic review and meta-analysis

BACKGROUND

An inability to identify or describe internal emotional experience has been linked to a range of affective disorders. Despite burgeoning research on mindfulness-based interventions and their possible effects on emotion regulation, the effects of such interventions on emotional clarity is unclear. This review examines the evidence for the effect of mindfulness-based interventions on self-reported emotional clarity.

METHOD

Published studies indexed by PsycINFO, PubMed and Scopus, as available in April 2017, were systematically reviewed. Interventions that included mindfulness practice or philosophy, and reported a suitable measure of emotional clarity at pre- and post-intervention were selected. A random-effects meta-analysis was performed. Subgroup comparisons were also conducted to test for differences between clinical and non-clinical samples, between specific and approximate measures of emotional clarity, and between controlled and uncontrolled trials.

RESULTS

Seventeen studies met the criteria for inclusion. The overall estimated effect size for pre- to post-intervention was small to moderate, Hedges' g = 0.42, 95% CI [0.25, 0.59] and for between groups results was small to large, Hedges' g = 0.52, 95% CI [0.15, 0.90].

LIMITATIONS

Studies varied substantially in design quality and study characteristics. Furthermore, while interventions in the reviewed studies all had mindfulness components, many had other components in addition to mindfulness. Consequently, this review is limited by the heterogeneity of studies and results should be interpreted with caution.

CONCLUSIONS

There is preliminary evidence to suggest that mindfulness-based interventions may increase emotional clarity. However, more homogenous and targeted experiments are required to confirm these initial findings.

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

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

Attachment and Reflective Functioning in Women With Borderline Personality Disorder

Insecure attachment and impairments in reflective functioning (RF) are thought to play a critical role in borderline personality disorder (BPD). In particular, the mentalization-based model argues that insecure attachment indirectly accounts for increased BPD features, notably via disruption of RF capacities. Although the mediation relationship between attachment, RF, and BPD is supported by previous evidence, it remains to be directly tested in adults with BPD. In the current study, a sample of 55 female adult BPD patients and 105 female healthy controls completed a battery of self-report measures to investigate the interplay between attachment, RF capacities, and BPD clinical status. Overall, the results showed that BPD patients pre- dominantly reported insecure attachment, characterized by negative internal working models of the self as unlovable and unimportant to others, and decreased RF abilities. Our findings further indicated that actual RF capacities mediated the relationships between adult insecure attachment and BPD clinical status.

Suicidal Ideation and Skill Use During In-patient Dialectical Behavior Therapy for Borderline Personality Disorder. A Diary Card Study

Associations between suicidal ideation and skill use were investigated during in-patient dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were N = 44 patients with BPD undergoing a 5-week in-patient DBT program in a psychiatric clinic. They filled in a diary card each treatment day resulting in 1,334 skill use ratings and 1,364 suicidal ideation ratings. Treatment days were categorized as days with successful skill use (using skills and perceiving them as effective), days with no skill use, days with unsuccessful skill use (using skills but perceiving them as ineffective). Multilevel models were performed to account for the nested data structure. The results showed that suicidal ideation improved more for patients who applied skills successfully more often during treatment (p < 0.05). Moreover, suicidal ideation was lower on treatment days with successful skill use compared to treatment days with no skill use and compared to treatment days with unsuccessful skill use (p < 0.05). When treatment days with no skill use were compared to treatment days with unsuccessful skill use, suicidal ideation was higher on treatment days with unsuccessful skill use (p < 0.05). To conclude, using skills successfully on as many treatment days as possible is associated with lower suicidal ideation.

EMOTEO: A Smartphone Application for Monitoring and Reducing Aversive Tension in Borderline Personality Disorder Patients, a Pilot Study

PURPOSE

We developed a smartphone application (App; EMOTEO: emotion-meteo [weather forecast]) to help borderline personality disorder (BPD) patients to monitor and regulate their inner tension. The App proposes targeted mindfulness-based exercises.

DESIGN AND METHODS

We assessed the usability and efficiency of this App for monitoring and reduction of aversive tension in 16 BPD participants over a 6-month period.

FINDINGS

We recorded a mean of 318.1 sessions (SD = 166.7) per participants, with a high level of satisfaction. There was a significant decrease in aversive tension (p < .05) and the App was mainly used around 10 a.m. and 9 p.m.

PRACTICE IMPLICATIONS

EMOTEO was user-friendly and efficient in reducing aversive tension in BPD patients.

Borderline Personality Disorder and the Effects of Instructed Emotional Avoidance or Acceptance in Daily Life

This study examined the effects of avoidance- versus acceptance-oriented emotion regulation instructions among individuals with borderline personality disorder (BPD; n = 48), major depressive disorder (MDD; n = 54), and non-psychiatric controls (NPC; n = 50) using ecological momentary assessment. Participants were randomly assigned to either accept or avoid negative emotions, and monitored their moods, urges, and distress tolerance several times per day over 6 days. Avoidance instructions resulted in reduced negative affect and urges for maladaptive behaviors uniquely among BPD participants. Together with past research, and consistent with treatment approaches emphasizing the short-term use of skills to avoid or distract from emotions (e.g., DBT; Linehan, 1993b, 2015), these findings suggest that avoidance of negative emotions may have temporary benefits for individuals with BPD. Acceptance-oriented strategies may take longer or may require more extensive training to be beneficial for emotional functioning in everyday life in BPD.

Mechanisms of change in dialectical behaviour therapy and cognitive behaviour therapy for borderline personality disorder: a critical review of the literature

Background: Little is known about the "active ingredients" of psychological therapy for Borderline Personality Disorder (BPD) despite a growing evidence base documenting its clinical effectiveness. This information can be used by clinicians to inform service planning and care pathways.Aims: The aim of this study was to review published empirical research investigating the potential mechanisms underlying therapeutic change in Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT) for BPD.Method: A thorough search of the PsychInfo, CINAHL Plus, PubMed, MEDLINE and EMBASE databases revealed research into potential mechanisms of change.Results: A total of 52 abstracts were reviewed. After a full text screen of the most relevant studies, 14 met inclusion criteria. Twelve examined DBT and two CBT. Mechanisms of change identified broadly fell into three categories: emotion regulation/self-control, skills use and therapeutic alliance/investment in treatment. Outcomes measured included general mental health diagnoses (e.g. anxiety, depression) and BPD-specific symptoms (e.g. self-harm/suicidality, impulsivity, substance misuse, anger).Conclusion: Further empirically robust research is required to test hypotheses about the influence of the proposed mechanisms on therapeutic change in psychological therapies for BPD.

Biofeedback

Although evidence supports the efficacy of biofeedback for treating a number of disorders and for enhancing performance, significant barriers block both needed research and payer support for this method. Biofeedback has demonstrated effects in changing psychophysiological substrates of various emotional, physical, and psychosomatic problems, but payers are reluctant to reimburse for biofeedback services. A considerable amount of biofeedback research is in the form of relatively small well-controlled trials (Phase II trials). This article argues for greater payer support and research support for larger trials in the “real life” clinical environment (Phase III trials) and meta-analytic reviews.

Does Mindfulness Enhance Critical Thinking? Evidence for the Mediating Effects of Executive Functioning in the Relationship between Mindfulness and Critical Thinking

Mindfulness originated in the Buddhist tradition as a way of cultivating clarity of thought. Despite the fact that this behavior is best captured using critical thinking (CT) assessments, no studies have examined the effects of mindfulness on CT or the mechanisms underlying any such possible relationship. Even so, mindfulness has been suggested as being beneficial for CT in higher education. CT is recognized as an important higher-order cognitive process which involves the ability to analyze and evaluate evidence and arguments. Such non-automatic, reflective responses generally require the engagement of executive functioning (EF) which includes updating, inhibition, and shifting of representations in working memory. Based on research showing that mindfulness enhances aspects of EF and certain higher-order cognitive processes, we hypothesized that individuals higher in facets of dispositional mindfulness would demonstrate greater CT performance, and that this relationship would be mediated by EF. Cross-sectional assessment of these constructs in a sample of 178 university students was achieved using the observing and non-reactivity sub-scales of the Five Factor Mindfulness Questionnaire, a battery of EF tasks and the Halpern Critical Thinking Assessment. Our hypotheses were tested by constructing a multiple meditation model which was analyzed using Structural Equation Modeling. Evidence was found for inhibition mediating the relationships between both observing and non-reactivity and CT in different ways. Indirect-only (or full) mediation was demonstrated for the relationship between observing, inhibition, and CT. Competitive mediation was demonstrated for the relationship between non-reactivity, inhibition, and CT. This suggests additional mediators of the relationship between non-reactivity and CT which are not accounted for in this model and have a negative effect on CT in addition to the positive effect mediated by inhibition. These findings are discussed in the context of the Default Interventionist Dual Process Theory of Higher-order Cognition and previous studies on mindfulness, self-regulation, EF, and higher-order cognition. In summary, dispositional mindfulness appears to facilitate CT performance and this effect is mediated by the inhibition component of EF. However, this relationship is not straightforward which suggests many possibilities for future research.

Mindfulness for personality disorders

PURPOSE OF REVIEW

Third-wave cognitive-behaviour therapies such as dialectical behaviour therapy have demonstrated effectiveness in the treatment of personality disorders, which are considered difficult to treat. These therapies typically incorporate some component of mindfulness practice. The current study examines current applications and effectiveness of mindfulness to the treatment of personality disorders.

RECENT FINDINGS

The majority of evidence available focuses on borderline personality disorder, and highlights positive associations between mindfulness practice and reduced psychiatric and clinical symptoms, less emotional reactivity, and less impulsivity. Fewer studies examine the other personality disorders, though emerging case studies have applied mindfulness techniques to treatment with antisocial, avoidant, paranoid, and obsessive-compulsive personality disorders.

SUMMARY

Mindfulness is a promising clinical tool for the treatment of personality disorders, and appears to be adaptable to the unique features of different types of personality disorders. However, further empirical research with greater methodological rigour is required to clarify the effectiveness of mindfulness as a specific skill component, and to identify the underlying mechanisms that contribute to therapeutic change.

Weekly fluctuations in nonjudging predict borderline personality disorder feature expression in women

OBJECTIVES

Borderline personality disorder (BPD) features have been linked to deficits in mindfulness, or nonjudgmental attention to present-moment stimuli. However, no previous work has examined the role of fluctuations in mindfulness over time in predicting BPD features. The present study examines the impact of both between-person differences and within-person changes in mindfulness.

DESIGN

40 women recruited to achieve a flat distribution of BPD features completed 4 weekly assessments of mindfulness (Five Facet Mindfulness Questionnaire; FFMQ) and BPD features. Multilevel models predicted each outcome from both 1) a person's average levels of each facet and 2) weekly deviations from a person's average for each facet.

RESULTS

Average acting with awareness, nonjudging, and nonreactivity predicted lower BPD features at the between-person level, and weekly deviations above one's average (i.e., higher-than-usual) nonjudging predicted lower BPD feature expression at the within-person level.

CONCLUSIONS

Within-person fluctuations in the nonjudging facet of mindfulness may be relevant to the daily expression of BPD features over and above dispositional mindfulness.

Addition of methylphenidate to intensive dialectical behaviour therapy for patients suffering from comorbid borderline personality disorder and ADHD: a naturalistic study

Attention deficit hyperactivity disorder (ADHD) is frequently comorbid with borderline personality disorder (BPD). However, few studies have examined how comorbid BPD-ADHD patients, treated or not with methylphenidate (MPH), respond to psychotherapy compared to non-comorbid BPD patients. In this perspective, we used a naturalistic study to compare, during a month-long intensive dialectical behaviour therapy (DBT), the clinical course of BPD patients and comorbid BPD-ADHD patients who were treated or untreated with MPH. Out of the 158 BPD patients recruited, 59 had adult ADHD as a comorbidity; among these, 29 underwent a treatment with MPH or des-methylphenidate, while the 30 others did not. MPH treatment was given non-randomly and only when ADHD was considered to be hampering the capacity of the subjects to follow the therapy. Patients completed the following forms upon admission and after 1 month of treatment: the adult ADHD Self-Report Scale (ASRS v.1.1), the Barratt Impulsiveness Scale (BIS-10), the State-Trait Anger Expression (STAXI), the Beck Depression Inventory II (BDI-II), and the Beck Hopelessness Scale. At baseline, comorbid BPD-ADHD patients showed significantly higher impulsiveness than BPD patients. In the entire sample, there was a significant decrease in all dimensions ranging from small to large effect sizes during the 4-week intensive DBT. BPD-ADHD patients who were undergoing MPH treatment showed a significantly improved response to DBT treatment for Trait-State Anger scores, motor impulsiveness, depression severity, and ADHD severity, when compared to those without stimulant medication. This study outlines the importance of systematically screening BPD patients for ADHD, since a MPH-based treatment will improve the symptoms of patients who are comorbid for BPD and ADHD. Due to the non-random allocation of subjects, more severely affected patients were more readily placed on MPH; this suggests that the more severe the ADHD symptoms, the greater the chance for the patient of being treated.

Regulation of sadness via acceptance or suppression in adult Attention Deficit Hyperactivity Disorder (ADHD)

Emotion dysregulation is a recognized symptom of adult Attention Deficit Hyperactivity Disorder (ADHD). The aim of this study is to induce sadness in adults suffering from ADHD and to investigate the impact of emotion regulation strategies on sadness intensity, and psychophysiological measures. Thirty-six adults diagnosed with ADHD were randomly assigned to either expressive suppression (SUPP) or acceptance (ACC) of emotion. Sadness was induced using a film clip. Participants estimated the intensity of sadness and the perception of being overwhelmed with emotion before (T1), immediately after (T2) and 2 min after the film (T3). Physiological measures were obtained. Sadness induction was effective in both conditions. The perception of being overwhelmed with emotion increased between T1 and T2 in both conditions, but persisted until T3 only in the expressive suppression condition whereas a decrease was observed in the acceptance condition. In ADHD expressive suppression of sadness seems to be associated to a prolonged recovery from the perception of being overwhelmed with emotion. Emotion-regulation via acceptance in contrast appears to allow faster recovery from the perception of being overwhelmed with emotion. To our knowledge, this is the first study to identify suppression as a critical mediator between an induced emotion and delayed recovery from emotional reactions in adult ADHD.

[Attentional bias and emotional suppression in borderline personality disorder]

OBJECTIVE

Emotion regulation dysfunctions marked by negative affectivity are a core feature of borderline personality disorder (BPD). In addition, patients with BPD show disturbed attentional processes which become particularly apparent in the domain of selective attention when emotional stimuli are presented (negative attentional bias). Assuming that emotion regulation is linked to attentional deployment processes, this study aimed (1) to determine whether a negative attentional bias is established by using film clips of fearful faces and (2) to investigate the association between dysfunctional emotion regulation strategies (emotional suppression) and negative attention bias in BPD.

METHODS

We investigated 18 inpatients with BPD and 18 healthy control participants using the modified version of the fearful face-paradigm to assess the inhibition of emotional stimuli. We also administered self-report emotion regulation questionnaires.

RESULTS

Compared to the healthy controls, patients with BPD showed significant longer reaction times during the emotional versus the neutral film stimuli in the modified fearful face-paradigm. With regard to the second hypothesis, we failed to find an association between the negative attentional bias and the habitual use of emotional suppression in BPD.

CONCLUSIONS

In this study, we could confirm an attentional bias for negative stimuli, using complex, dynamic material. Future studies need to address the impact of confounding variables (e. g. comorbid disorders) on the relationship between maladaptive emotion regulation and selective attentional bias.

Distinguishing borderline personality disorder from adult attention deficit/hyperactivity disorder: a clinical and dimensional perspective

Adult attention deficit hyperactivity disorder (ADHD) is frequently associated with borderline personality disorder (BPD). As both disorders share some core clinical features they are sometimes difficult to distinguish from one another. The present work aimed to investigate differences in the expression of impulsivity, anger and aggression, quality of life as well as the number and severity of the comorbidities between ADHD, BPD, comorbid BPD-ADHD and control subjects. ADHD and BPD-ADHD patients showed a higher level of impulsivity than BPD and control subjects. BPD-ADHD patients had higher levels of substance abuse/dependence and higher levels of aggression than the other groups. Comorbid BPD-ADHD patients showed high levels of impulsivity and aggression, a characteristic that should draw the attention of clinicians on the necessity of providing an accurate diagnosis. The question also arises as to whether they represent a distinct clinical subgroup with specific clinical characteristics, outcomes and vulnerability factors.

Increased attempts to suppress negative and positive emotions in Borderline Personality Disorder

Patients with Borderline Personality Disorder (BPD) show evidence of disturbed emotion regulation. In particular, patients may try to suppress their emotions with possibly negative effects on mental health. We investigated the suppression of both negative and positive emotions in BPD patients and healthy participants. Thirty BPD patients and 30 matched healthy controls were assessed for emotion suppression using the Emotion Acceptance Questionnaire (EAQ). In addition, we administered additional questionnaires to validate emotion suppression findings. BPD patients reported increased attempts to suppress both negative and positive emotions. These findings indicate that BPD patients are not simply acting out negative emotions. Therapeutic approaches that focus on emotion acceptance of emotions are supported by our study data. Apart from negative emotions, treatment programs should consider positive emotions as well.

Response to psychotherapy in borderline personality disorder and methylation status of the BDNF gene

Downregulation of brain-derived neurotrophic factor (BDNF) gene expression with corresponding increased methylation at specific promoters has been associated with stressful experiences in early life and may explain later adulthood psychopathology. We measured the percentage of methylation at BDNF CpG exons I and IV as well as plasma BDNF protein levels in 115 subjects with borderline personality disorder (BPD) and 52 controls. BPD subjects then underwent a 4-week course of intensive dialectical behavior therapy (I-DBT). BDNF methylation status and protein levels were re-assessed at the end of treatment. BPD subjects had significantly higher methylation status in both CpG regions than controls. In addition, the higher the number of childhood trauma, the higher was the methylation status. In BPD subjects, BDNF methylation significantly increased after I-DBT. Nonresponders accounted for the majority of this increase, whereas responders showed a decrease in methylation status over time. Accordingly, the changes in methylation status over time were significantly associated with changes in depression scores, hopelessness scores and impulsivity. No association was found between protein levels and BDNF methylation status. We here found a relationship between child maltreatment and higher DNA methylation of BDNF. These results moreover support the idea that these epigenetic marks may be changed through psychotherapeutic approaches and that these changes underline changes in cognitive functions.