The role of emotion dysregulation and interpersonal dysfunction in nonsuicidal self-injury during dialectical behavior therapy for borderline personality disorder.

Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), with findings demonstrating improvements in various BPD features and related behaviours, such as nonsuicidal self-injury (NSSI). Theory and research suggest that reductions in emotion dysregulation and interpersonal dysfunction could account for at least some of the reduction in NSSI observed during the course of DBT. The current research investigated: 1) the trajectory of changes in emotion dysregulation, interpersonal dysfunction, and NSSI over the course of DBT, and 2) whether changes in emotion dysregulation mediate the relationship between changes in interpersonal dysfunction and changes in NSSI over treatment. One hundred and twenty individuals with BPD enrolled in a multi-site randomized-clinical trial were assessed at five timepoints over 12 months of standard DBT. Results indicated that interpersonal dysfunction and NSSI decreased over the course of DBT. Emotion dysregulation decreased in a quadratic manner such that most of the gains in emotion dysregulation occurred in earlier phases of DBT. Although changes in interpersonal dysfunction predicted changes in emotion dysregulation, changes in emotion dysregulation did not mediate the relationship between changes in interpersonal dysfunction and changes in NSSI.

Using machine learning to increase access to and engagement with trauma-focused interventions for posttraumatic stress disorder.

BACKGROUND: Post-traumatic stress disorder (PTSD) poses a global public health challenge. Evidence-based psychotherapies (EBPs) for PTSD reduce symptoms and improve functioning (Forbes et al., Guilford Press, 2020, 3). However, a number of barriers to access and engagement with these interventions prevail. As a result, the use of EBPs in community settings remains disappointingly low (Charney et al., Psychological Trauma: Theory, Research, Practice, and Policy, 11, 2019, 793; Richards et al., Community Mental Health Journal, 53, 2017, 215), and not all patients who receive an EBP for PTSD benefit optimally (Asmundson et al., Cognitive Behaviour Therapy, 48, 2019, 1). Advancements in artificial intelligence (AI) have introduced new possibilities for increasinfg access to and quality of mental health interventions. AIMS: The present paper reviews key barriers to accessing and engaging in EBPs for PTSD, discusses current applications of AI in PTSD treatment and provides recommendations for future AI integrations aimed at reducing barriers to access and engagement. DISCUSSION: We propose that AI may be utilized to (1) assess treatment fidelity; (2) elucidate novel predictors of treatment dropout and outcomes; and (3) facilitate patient engagement with the tasks of therapy, including therapy practice. Potential avenues for technological advancements are also considered.

The role of mindfulness and emotion regulation in dialectical behavioral therapy for borderline personality disorder.

Despite nearly 30 years of research demonstrating its effectiveness in the treatment of borderline personality disorder (BPD) and related problems, few studies have investigated mechanisms of change for dialectical behavior therapy (DBT; Linehan, 1993a). Improvements in mindfulness and emotion regulation have been highlighted as key potential mechanisms of change in DBT (Lynch et al., 2006). The present study examined the time course of and associations between mindfulness, emotion regulation, and BPD symptoms during DBT. Participants were 240 repeatedly and recently self-harming adults (Mage = 27.75) with BPD who were randomly assigned to receive either 6 or 12 months of standard DBT. Primary hypotheses were that: (a) changes in mindfulness would occur before changes in emotion regulation, and (b) changes in emotion regulation would mediate the association of changes in mindfulness with changes in BPD symptoms. Results from changepoint analysis illuminated the proportion of participants for whom first changes occurred in emotion regulation (40.7%), mindfulness (32.4%), or both (26.9%). Contrary to hypotheses, five-wave, cross-lagged analyses did not indicate mediational effects of either mindfulness or emotion regulation on the association of either variable with change in BPD symptoms. Supplemental analyses, however, suggested that changes in emotion regulation mediated the inverse association of changes in mindfulness with changes in BPD symptoms. Findings highlight patterns of change in key, proposed mechanisms of change in DBT and suggest important future research directions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Pretreatment cognitive performance is associated with differential self-harm outcomes in 6 v. 12-months of dialectical behavior therapy for borderline personality disorder.

BACKGROUND: Recent findings suggest that brief dialectical behavior therapy (DBT) for borderline personality disorder is effective for reducing self-harm, but it remains unknown which patients are likely to improve in brief v. 12 months of DBT. Research is needed to identify patient characteristics that moderate outcomes. Here, we characterized changes in cognition across brief DBT (DBT-6) v. a standard 12-month course (DBT-12) and examined whether cognition predicted self-harm outcomes in each arm. METHODS: In this secondary analysis of 240 participants in the FASTER study (NCT02387736), cognitive measures were administered at pre-treatment, after 6 months, and at 12 months. Self-harm was assessed from pre-treatment to 2-year follow-up. Multilevel models characterized changes in cognition across treatment. Generalized estimating equations examined whether pre-treatment cognitive performance predicted self-harm outcomes in each arm. RESULTS: Cognitive performance improved in both arms after 6 months of treatment, with no between-arm differences at 12-months. Pre-treatment inhibitory control was associated with different self-harm outcomes in DBT-6 v. DBT-12. For participants with average inhibitory control, self-harm outcomes were significantly better when assigned to DBT-12, relative to DBT-6, at 9-18 months after initiating treatment. In contrast, participants with poor inhibitory control showed better self-harm outcomes when assigned to brief DBT-6 v. DBT-12, at 12-24 months after initiating treatment. CONCLUSIONS: This work represents an initial step toward an improved understanding of patient profiles that are best suited to briefer v. standard 12 months of DBT, but observed effects should be replicated in a waitlist-controlled study to confirm that they were treatment-specific.

The influence of sleep on emotion dysregulation in borderline personality disorder, generalized anxiety disorder, and healthy controls.

Emotion dysregulation is central to borderline personality disorder (BPD) and exacerbated by sleep disruptions. This study investigated whether homeostatic (i.e., sleep efficiency), circadian (i.e., chronotype), and subjective (i.e., sleep quality) sleep elements predict emotion dysregulation in BPD, healthy controls (HCs), and a generalized anxiety disorder (GAD) group. Participants (N = 120) with BPD, GAD, and HCs completed daily sleep measures for seven days prior to an experiment wherein baseline emotion, emotional reactions to stressors (i.e., reactivity), and the extent to which they can decrease their emotion using mindfulness and distraction (i.e., emotion regulation) were measured across self-reported, sympathetic, and parasympathetic emotion. Across groups, earlier chronotypes and higher sleep quality predicted less self-reported baseline negative emotion, and higher sleep quality predicted better parasympathetic emotion regulation. For HCs, higher sleep efficiency and lower sleep quality predicted higher parasympathetic baseline emotion, and higher sleep efficiency predicted more self-reported baseline negative emotion. Also in HCs, earlier chronotype predicted better sympathetic emotion regulation, and there was a quadratic relationship between sleep efficiency and self-reported emotion regulation. Optimizing sleep quality and improving alignment between chronotype and daily living may improve baseline emotion and emotion regulation. Healthy individuals may be particularly vulnerable to high or low sleep efficiency.

Subgroups of borderline personality disorder: A latent class analysis.

Borderline personality disorder (BPD) is characterized by instability in interpersonal, affective, cognitive, self-identity, and behavioral domains. For a BPD diagnosis, individuals must present at least five of nine symptoms, resulting in 256 possible symptom combinations; thus, individuals diagnosed with BPD can differ substantially. Specific symptoms of BPD tend to co-occur, suggesting BPD subgroups. To explore this potential, we analyzed data from 504 participants diagnosed with BPD enrolled in one of three randomized controlled trials conducted at center for Addiction and Mental Health in Toronto, Canada from 2002 to 2018. An exploratory latent class analysis (LCA) was conducted to identify symptom subgroups of BPD. Analyses indicated three latent subgroups. The first group (n = 53) is distinguished by a lack of affective instability and low levels of dissociative symptoms (non-labile type). The second group (n = 279) is characterized by high levels of dissociative and paranoid symptoms but low abandonment fears and identity disturbance (dissociative/paranoid type). The third group (n = 172) is characterized by high efforts to avoid abandonment and interpersonal aggression (interpersonally unstable type). Homogenous symptom subgroups of BPD symptoms exist and may have important implications for how to refine BPD treatment interventions.

The Effectiveness of 6 versus 12 Months of Dialectical Behavior Therapy for Borderline Personality Disorder: A Noninferiority Randomized Clinical Trial.

INTRODUCTION: Evidence-based psychotherapies for borderline personality disorder (BPD) are lengthy, posing a barrier to their access. Brief psychotherapy may achieve comparable outcomes to long-term psychotherapy for BPD. Evidence is needed regarding the comparative effectiveness of short- versus long-term psychotherapy for BPD. OBJECTIVE: The aim was to determine if 6 months of Dialectical Behavior Therapy (DBT) is noninferior to 12 months of DBT in terms of clinical effectiveness. METHODS: This two-arm, single-blinded, randomized controlled noninferiority trial with suicidal or self-harming patients with BPD was conducted at two sites in Canada. Participants (N = 240, M (SD)age = 28.27 (8.62), 79% females) were randomized to receive either 6 (DBT-6) or 12 months (DBT-12) of comprehensive DBT. Masked assessors obtained measures of clinical effectiveness at baseline and every 3 months, ending at month 24. DBT-6 and DBT-12 were outpatient treatments consisting of weekly individual therapy sessions, weekly DBT skills training group sessions, telephone consultation as needed, and weekly therapist consultation team meetings. RESULTS: The noninferiority hypothesis was supported for the primary outcome, total self-harm (6 months: margin = -1.94, Mdiff [95% CI] = 0.16 [-0.14, 0.46]; 12 months: margin = -1.47, Mdiff [95% CI] = 0.04 [-0.17, 0.23]; 24 months: margin = -1.25, Mdiff [95% CI] = 0.12 [-0.02, 0.36]). Results also supported noninferiority of DBT-6 for general psychopathology and coping skills at 24 months. Furthermore, DBT-6 participants showed more rapid reductions in BPD symptoms and general psychopathology. There were no between-group differences in dropout rates. CONCLUSIONS: The noninferiority of a briefer yet comprehensive treatment for BPD has potential to reduce barriers to treatment access.

The who and what of validation: an experimental examination of validation and invalidation of specific emotions and the moderating effect of emotion dysregulation.

BACKGROUND: Theory and research indicate that validation is associated with reductions in negative emotions, whereas invalidation is associated with escalation of negative emotions. However, it remains unclear whether these effects are consistent across emotions, and/or moderated by an individual's levels of emotion dysregulation. The present study experimentally examines the effects of validation and invalidation across emotions and as moderated by emotion dysregulation. METHODS: One hundred twenty-six participants completed a measure of emotion dysregulation, and then listened to a rejection-themed imagery script after which they reported the intensity of several emotions. Participants were then presented with either validating or invalidating feedback about their most intense self-reported emotion, depending on their counterbalancing order. They then repeated the procedure for the other condition. Self-reported negative emotions via continuous rating dial, heart rate (HR), and skin conductance level (SCL) were monitored throughout. RESULTS: Higher emotion dysregulation was associated with greater increases in self-reported positive emotion when shame or sadness was validated and lesser increases when fear was validated. There were no significant moderating effects of emotion dysregulation in response to invalidation for any emotion on any index. CONCLUSIONS: The effects of validation appear emotion specific and dependent on levels of emotion dysregulation. These findings may help inform more strategic use of validation in psychotherapeutic interventions.

Is borderline personality disorder really an emotion dysregulation disorder and, if so, how? A comprehensive experimental paradigm.

BACKGROUND: Leading theories suggest that borderline personality disorder (BPD) is an emotion dysregulation disorder involving lower basal vagal tone, higher baseline emotion, heightened emotional reactivity, delayed emotional recovery, and emotion regulation deficits. However, the literature to date lacks a unifying paradigm that tests all of the main emotion dysregulation components and comprehensively examines whether BPD is an emotion dysregulation disorder and, if so, in what ways. This study addresses the empirical gaps with a unified paradigm that assessed whether BPD is characterized by five leading emotion dysregulation components compared to generalized anxiety disorder (GAD) and healthy control (HC) groups. METHODS: Emotion was assessed across self-report, sympathetic, and parasympathetic indices. Participants with BPD, GAD, and HCs (N = 120) first underwent baseline periods assessing basal vagal tone and baseline emotional intensity, followed by rejection-themed stressors assessing emotional reactivity. Participants then either reacted normally to assess emotional recovery or attempted to decrease emotion using mindfulness or distraction to assess emotion regulation implementation deficits. RESULTS: Individuals with BPD and GAD exhibited higher self-reported and sympathetic baseline emotion compared to HCs. The BPD group also exhibited self-reported emotion regulation deficits using distraction only compared to the GAD group. CONCLUSIONS: There is minimal support for several emotion dysregulation components in BPD, and some components that are present appear to be pervasive across high emotion dysregulation groups rather than specific to BPD. However, BPD may be characterized by problems disengaging from emotion using distraction.

Predicting the effectiveness of engagement and disengagement emotion regulation based on emotional reactivity in borderline personality disorder.

Improving emotion regulation is central to borderline personality disorder (BPD) treatment, but little research indicates which emotion regulation strategies are optimally effective and when. Basic emotion science suggests that engagement emotion regulation strategies that process emotional content become less effective as emotional intensity increases, whereas disengagement strategies that disengage from it do not. This study examined whether emotional reactivity to emotional stimuli predicts the effectiveness of engagement and disengagement emotion regulation across self-report, general physiologic (heart rate), sympathetic (skin conductance responses), and parasympathetic (respiratory sinus arrythmia) emotion in BPD, healthy, and clinical control (i.e. generalized anxiety disorder; GAD) groups. 120 participants (40 per group) were exposed to emotion inductions and then instructed to implement engagement (mindful awareness) and disengagement (distraction) strategies while self-report and physiological emotion measurements were taken. In the BPD and GAD groups, higher heart rate or respiratory sinus arrythmia reactivity, respectively, predicted improved mindful awareness effectiveness. Higher skin conductance reactivity predicted worsened distraction effectiveness in BPD. Higher reactivity may potentiate engagement emotion regulation, and exacerbate disengagement from emotional content, in BPD. Future research should examine other domains of emotion regulation that may be influenced by emotional intensity, and other forms of emotional intensity that may influence them.

An experience sampling investigation of emotion and worry in people with generalized anxiety disorder.

Emotion-oriented theories (e.g., emotion dysregulation model, Mennin et al., 2005; contrast avoidance model; Newman & Llera, 2011) posit that people with Generalized Anxiety Disorder (GAD) have disturbances in emotion, experience negative emotion as aversive and in turn use maladaptive strategies, including worry, to regulate their distress. Much of what is known about emotion in the context of GAD is based on studies employing static methodologies. It is proposed that constructs and methodologies from the literature on emotion dynamics offer a complementary perspective. The principal aims of the study were to identify an emotion profile for people with GAD and to examine the direct effect of worry on subsequent negative and positive emotions via the experience sampling method. Participants included people with GAD (GAD group; n = 39) and people without GAD (nonclinical control [NCC] group; n = 41). Relative to the NCC group, the GAD group exhibited an emotion profile characterized by elevated mean intensity, greater instability and greater inertia of negative emotions and lower mean intensity, greater instability of positive emotions, but did not differ on inertia of positive emotions. People with GAD were found to have greater worry inertia and worry was also found to be associated with a subsequent increase in negative emotion, and this was more pronounced for the GAD group relative to the NCC group. The findings inform emotion-oriented models, provide unique insights into the dynamic emotional experiences of those with GAD and reinforce the benefits of the experience sampling methodology to study GAD-relevant processes.

The moderating effects of anger suppression and anger expression on cognitive behavioral group therapy and mindfulness-based stress reduction among individuals with social anxiety disorder.

BACKGROUND: . Cognitive-behavioral therapy and mindfulness-based stress reduction (MBSR) are two prominent evidence-based treatments for social anxiety disorder (SAD). It is not clear, however, whether outcomes of these two treatments are moderated by similar factors. For example, whereas anger suppression and anger expression each predict outcomes in cognitive- behavioral group therapy (CBGT), it is unknown whether they differentially influence outcomes in CBGT versus MBSR. METHODS: . One hundred eight participants with SAD were randomized to CBGT, MBSR or Waitlist (WL). WL participants were later randomized to CBGT or MBSR, and their data were combined with data from those originally randomized to CBGT or MBSR. Anger suppression and anger expression were assessed at pre-treatment, and social anxiety was assessed at pre-treatment, post-treatment, and every 3 months throughout a 12-month follow-up period. RESULTS: . From pre- to post-treatment, higher anger suppression was associated with significantly greater reduction in social anxiety in CBGT compared with MBSR. From post-treatment through follow-up, higher anger expression was associated lesser reduction in social anxiety in MBSR but not in CBGT. LIMITATIONS: . Data are limited by sole reliance on self-report and it is unclear whether these findings generalize beyond group-based interventions. CONCLUSIONS: . Individuals with SAD who are higher in anger suppression and/or expression might be better suited to CBGT than MBSR.

On loving thyself: Exploring the association between self-compassion, self-reported suicidal behaviors, and implicit suicidality among college students.

OBJECTIVE: Suicide is a major public health concern. It is unknown whether self-compassion is associated with suicide risk above and beyond suicide risk factors such as self-criticism, hopelessness, and depression severity. Participants: Participants were 130 ethnically diverse undergraduate college students. Methods: Participants completed self-report measures of self-compassion, self-criticism, hopelessness, depression severity, and suicidal behaviors, as well as an implicit measure of suicidality. Results: Self-compassion was significantly associated with self-reported suicidal behaviors, even when controlling for self-criticism, hopelessness, and depression severity. Self-compassion was not significantly associated with implicit suicidality. Conclusions: The findings suggest that self-compassion is uniquely associated with self-reported suicidal behaviors, but not implicit suicidality, and that self-compassion is a potentially important target in suicide risk interventions. Limitations and future research directions are discussed.

Identifying specific insomnia components in borderline personality disorder and their influence on emotion dysregulation.

Insomnia-related sleep problems are common in borderline personality disorder (BPD) and exacerbate the core of BPD, emotion dysregulation. Insomnia is elicited and maintained through behaviors that disrupt both the homeostatic and circadian sleep systems. However, it is unclear which homeostatic or circadian insomnia behaviors characterize BPD and exacerbate emotion dysregulation, thus warranting clinical attention in this population. This study therefore investigated whether homeostatic (i.e., abnormalities in time in bed and sleep efficiency [SE]) and circadian (i.e., abnormalities in risetime variability and chronotypes) behaviors characterize and exacerbate emotion dysregulation in BPD group relative to healthy control (HC) and generalized anxiety disorder (GAD) groups. Participants from the community who met criteria for BPD, GAD, or no psychological disorders (HCs) were recruited and completed measures of emotion dysregulation. They also completed measures of daily homeostatic and circadian insomnia behaviors for 14 days. Generalized estimating equations revealed that the GAD group exhibited lower SE than HCs, and there was a marginally significant effect wherein the BPD group exhibited delayed risetimes relative to the GAD group. Moreover, higher time in bed predicted elevated emotion dysregulation in HCs but lower emotion dysregulation in the GAD group. Higher SE predicted higher emotion dysregulation in BPD. These results suggest that the influence of insomnia behaviors on emotion dysregulation is heterogeneous. Idiographic assessments of the influence of insomnia behaviors on emotion dysregulation are advised. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Getting Specific about Emotion and Self-Inflicted Injury: An Examination Across Emotion Processes in Borderline Personality Disorder.

This study aimed to examine which specific emotion processes influence self-inflicted injury: basal respiratory sinus arrhythmia, baseline negative emotional intensity, emotional reactivity, or emotion regulation deficits. Self-injuring individuals with borderline personality disorder (N = 22) reported their lifetime self-injury frequency. Basal respiratory sinus arrhythmia and baseline skin conductance responses measurements were collected. Participants then either reacted as they usually would (i.e., emotional reactivity), or utilized mindfulness- or distraction-based strategies (i.e., emotion regulation), in response to negative images while self-reported negative emotion and skin conductance were monitored. Higher basal respiratory sinus arrhythmia and baseline emotional intensity predicted higher lifetime self-injury frequency. Chronic, resting emotion processes may be more important targets for reducing self-injury compared to labile, acute emotion processes.

Investigating the therapeutic potential of cognitive bias modification for high anxiety sensitivity.

BACKGROUND AND OBJECTIVES: Individuals with high anxiety sensitivity (AS) display negative interpretive biases in response to uncomfortable but nondangerous physical sensations. Research suggests that modifying interpretation biases associated with AS leads to changes in AS. The present study sought to replicate and extend this research by addressing limitations of previous studies, increasing the amount of training and adding a follow-up period. METHOD: Participants high in AS were randomly assigned to four sessions of computerized interpretation bias modification (CBM-I) training or four sessions of computerized "sham" training (control condition) over a 2-week period. The outcomes were AS, interpretive biases, and reactions to induced physical sensations. Assessments occurred at baseline, during training, immediately after the final training session, and 2 weeks after the final training; number of re-assessments varied by outcome. RESULTS: The CBM-I condition did not outperform the control condition. At the end of the training period, the CBM-I condition displayed limited reductions in AS and interpretation biases. There were no changes in reactions to induced physical sensations. Similar results were found in the control condition for all outcomes. LIMITATIONS: The control task and the dose of training may have obscured potential effects of CBM-I. CONCLUSIONS: When considered within the context of previous research, the experimental effects and therapeutic potential of CBM-I for high AS appear to be minimal. However, methodological questions need to be resolved before such a conclusion can be considered definitive.

Use your words: The role of emotion labeling in regulating emotion in borderline personality disorder.

Borderline personality disorder (BPD) treatments emphasize emotion labeling to decrease negative emotion and facilitate emotion regulation. However, no studies have examined emotion labeling in BPD or its impact on intentional emotion regulation. The present study examined the impact of emotion labeling on emotion and intentional emotion regulation attempts across self-reported and physiological indices (i.e., skin conductance response [SCR], respiratory sinus arrhythmia [RSA]) in BPD and healthy control (HC) groups. Participants listened to emotionally-evocative scripts and were either instructed to type the emotions that they were experiencing (labeling) or the objects they could imagine seeing in the script (control) into a computer. Following this, they were instructed to use either mindfulness or cognitive reappraisal to decrease their emotion. Self-reported, RSA, and SCR indices of negative emotion were collected throughout and analyzed using generalized estimating equations. Findings indicated that the BPD group experienced higher RSA during emotion labeling compared to the control task, but the HC group did not. HCs reported lower negative emotion after emotion labeling when implementing both emotion regulation strategies compared to the control task, but the BPD group did not. These findings suggest that emotion labeling may activate emotion regulatory systems in BPD and can potentiate intentional emotion regulation in HCs.

An examination of emotion dysregulation in maladaptive perfectionism.

Maladaptive perfectionism has been shown to be associated with undesirable outcomes, such as elevated negative emotions and psychopathological traits. Perhaps unsurprisingly, there is preliminary evidence that maladaptive perfectionism is also related to emotion dysregulation. However, the nature of emotion dysregulation in perfectionism has not been characterized. In this review, Gross and Jazaieri's (2014) clinically-informed framework of emotion dysregulation is used to review the evidence of emotion dysregulation in maladaptive perfectionism. Specifically, this paper reviews evidence of problematic emotional experiences and unhelpful emotion regulation strategies in maladaptive perfectionism and discusses how poor emotional awareness and emotion regulation goals may also contribute to emotion dysregulation. A conceptual model of these components of emotion dysregulation in maladaptive perfectionism is proposed in which heightened negative affect in response to threatened perfectionistic standards is posited to be at the core of emotion dysregulation, and implicit and explicit unhelpful emotion regulation strategies and poor emotion regulation goals are suggested to contribute to further dysregulation and elevated negative affect. Clinical implications, limitations in the extant research, and future directions are discussed.

The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol.

BACKGROUND: Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment. METHODS/DESIGN: Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months. DISCUSSION: This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment. TRIAL REGISTRATION: NCT02387736 . Registered February 20, 2015.

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.