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.

Randomized effectiveness-implementation trial of dialectical behavior therapy interventions for young people with borderline personality disorder symptoms.

OBJECTIVES: Dialectical behavior therapy (DBT) is an evidence-based treatment for people with emerging borderline personality disorder (BPD). In "real world" clinical settings, standard DBT is resource intensive. Emerging evidence suggests that group-based DBT skills training alone can lead to promising outcomes. This hybrid type 1 effectiveness-implementation trial directly compared the effectiveness of an 8-week group DBT-skills training program and a 16-week DBT-informed program including individual treatment and group-based skills training. METHODS: This pragmatic trial employed a staggered, parallel-groups design. We recruited 104 participants, aged 16-25 years, with emotion dysregulation or emerging BPD symptoms. Participants were randomized to receive either program at a youth mental health service located in the Gold Coast, Australia. Data was collected via online surveys at baseline, 8-week, 16-week, and 24-week follow-up. Mixed effect linear models compared groups on the primary outcomes of emotion dysregulation and BPD symptoms, and secondary outcomes of suicidal ideation, coping skills, depression, anxiety, and stress. RESULTS: Across groups there were significant and sustained improvements relating to emotion dysregulation, BPD symptoms, stress, depression, and emotion-focused coping; but not suicide risk, anxiety, or task-focused coping. There was no significant time by group differences between the 8-week and 16-week interventions on any primary or secondary outcome. CONCLUSION: The more intensive mode of delivering DBT was not more effective than the brief group-based skills training. Both interventions resulted in significant improvements across both primary and most secondary outcomes. These results have implications for clinical practice regarding length and intensity of DBT treatment in young people.

Effectiveness of Dialectical Behavior Therapy (DBT) in a Forensic Psychiatric Hospital.

Dialectical behavior therapy (DBT) has strong evidence in support of its effectiveness in reducing suicide attempts, anger, impulsivity, and substance abuse. It has been implemented in a variety of forensic settings to help with these challenges, despite limited research on the efficacy of DBT within this population. The current study presents treatment outcomes from an established DBT program in a maximum-security forensic facility. Outcomes included self-reported functioning, behavioral outcomes, and assessment of DBT skills knowledge among inpatients who participated in either comprehensive DBT or DBT skills training. Behaviorally, the study found a significant decrease in rates of patient assaults and reduced use of "Pro re nata" (PRN) medication for anxiety or agitation over the course of DBT treatment. During the first six months of treatment, self-reported symptoms of depression, emotional and behavioral dysregulation, and psychological inflexibility significantly decreased. Within this time frame, patients also displayed a significant decrease in the use of dysfunctional coping skills and a significant increase in knowledge pertaining to emotion regulation and interpersonal effectiveness. The results of this study largely support the use of DBT in forensic settings.

Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment-A naturalistic study.

Dialectical behavior therapy (DBT) is widely acknowledged as an effective treatment for individuals with borderline personality disorder (BPD). However, the optimal treatment duration within DBT remains a topic of investigation. This retrospective, naturalistic non-randomized study aimed to compare the efficacy of 8 week and 12 week DBT interventions with equivalent content, focusing on the change of BPD-specific symptomatology as the primary outcome and depressive symptoms as the secondary outcome. Overall, 175 patients who participated in DBT and received either 8 week or 12 week intervention were included in the analysis. Routine inpatient treatment was adapted from standard DBT with the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. Measurements were taken at baseline, mid-point, and endpoint. The borderline symptom list-23 (BSL-23) was used for the assessment of borderline-specific symptoms, while the Beck depression inventory-II (BDI-II) was used for the assessment of depressive symptoms. Statistical analysis was conducted using linear mixed models. Effect sizes were calculated for both measures. The results of the analysis indicated an improvement in both groups over time. Effect sizes were d = 1.29 for BSL-23 and d = 1.79 for BDI-II in the 8 week group, and d = 1.16 for BSL-23 and d = 1.58 for BDI-II in the 12 week group. However, there were no differences in the change of BPD-specific symptoms or the severity of depressive symptoms between the 8 week and 12 week treatment duration groups. Based on these findings, shorter treatment durations, like 8 weeks, could be a viable alternative, offering comparable therapeutic benefits, potential cost reduction, and improved accessibility. However, further research is needed to explore factors influencing treatment outcomes and evaluate the long-term effects of different treatment durations in DBT for BPD.Trial registration: drks.de (DRKS00030939) registered 19/12/2022.

Exploring Preclinical Medical Students' Experience Facilitating Group Dialectical Behavior Therapy (DBT) for a Student-Run Mental Health Clinic: A Qualitative Study.

OBJECTIVE: This report explores the experiences of preclinical medical students who led group dialectical behavior therapy (DBT) for a student-run LGBTQ + mental health clinic. METHODS: In the clinic, experienced clinicians trained and supervised preclinical medical students to facilitate DBT groups. The authors conducted a qualitative study to understand the impact of the DBT groups on the student facilitators via semi-structured interviews, which were evaluated using thematic analysis. RESULTS: The clinic hosted nine iterations of group DBT facilitated by preclinical medical students, involving 18 student leaders and 30 patients. Twelve student facilitators were interviewed. Participants had a diverse array of specialty interests and were primarily motivated by the opportunity for early clinical experience. They reported improved clinical skills, increased appreciation of psychotherapy as a treatment modality, and increased interest in incorporating psychotherapy in their future practice. Furthermore, participants reported using DBT skills to cultivate wellbeing during clerkship year and in their personal lives. CONCLUSIONS: Offering preclinical medical students the opportunity to lead group DBT therapy is a novel educational model providing early training in psychotherapy techniques. This opportunity for early direct patient experience in a supervised group setting attracted medical students with a diverse range of specialty interests. This model provided medical students specific DBT skills to implement in future patient care interactions and to maintain their personal wellbeing throughout medical training. The broad appeal and lasting effects of this program may prove beneficial at other institutions.

Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder.

OBJECTIVE: We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths. METHOD: We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM). RESULTS: A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment. CONCLUSION: Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

The effectiveness and safety of dialectical behavior therapy for suicidal ideation and behavior in autistic adults: a pragmatic randomized controlled trial.

BACKGROUNDS: Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT) v. treatment as usual (TAU) in reducing suicidal ideation and suicide attempts. METHODS: At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group (n = 63) or TAU control group (n = 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes. RESULTS: At end-of-treatment, DBT significantly reduced both suicidal ideation (z = -2.24; p = 0.025; b = -4.41; s.e. = 197.0) and suicide attempts (z = -3.15; p = 0.002; IRR = 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT (z = -1.99; p = 0.046: b = -2.74; s.e. = 1.37) remaining so at 12 months (z = -2.46; p = 0.014; b = -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition. CONCLUSIONS: DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.

Telehealth-Delivered Radically Open Dialectical Behavior Therapy for Adolescents (RO DBT-A): A Pilot Mixed-Methods Study.

OBJECTIVE: Disorders related to overcontrol frequently first appear during adolescence, are highly comorbid, and show limited treatment response, necessitating the adaptation of radically open dialectical behavior therapy (RO DBT; a transdiagnostic treatment targeting overcontrol) for adolescents (RO DBT-A). This study tested the preliminary efficacy of telehealth-delivered RO DBT-A in a heterogeneous clinical sample of youths. METHODS: The sample consisted of 20 female participants ages 13-21 with elevated overcontrol; most were White (75%) and non-Hispanic/Latino (80%). RO DBT-A was provided over 20 weeks via skills group and individual sessions (N=13 participants). Participants seeking other treatment or no treatment formed the control group (N=7). Outcomes included self-reported symptoms and overcontrol. Follow-up interviews were analyzed by using inductive, contextualist thematic analysis to examine participant perceptions and reasons for dropout. RESULTS: The RO DBT-A group showed significant improvements in depression (t=-1.78, df=10, p=0.011) and quality of life (QOL; Wilcoxon W=75, p=0.021) compared with the control group. From baseline to posttreatment, youths receiving RO DBT-A demonstrated significant improvements in maladaptive overcontrol (t=2.76, df=12, p=0.043), anxiety (t=2.91, df=12, p=0.043), depression (Wilcoxon signed rank V=82.5, p=0.043), and QOL (t=-3.01, df=12, p=0.043). Qualitative analysis revealed themes related to treatment barriers, facilitators, and timing. CONCLUSIONS: The findings provide preliminary evidence supporting telehealth-delivered RO DBT-A in targeting overcontrol, decreasing symptomatology, and improving QOL in a heterogeneous clinical sample of youths. Qualitative follow-ups highlighted that dropout was driven by barriers related to therapy (e.g., structure- and therapist-related issues) and the timing of RO DBT-A compared with other treatments.

Leveling Up Dialectical Behavior Therapy for Autistic Individuals with Emotion Dysregulation: Clinical and Personal Insights.

Autistic people may experience high emotion and sensory sensitivities and a slow return to baseline emotional state. Dialectical behavior therapy (DBT) was developed to address reactivity, impulsivity, and mood dysregulation in individuals with mood and personality disorders. DBT may be therapeutically beneficial to autistic individuals struggling with these or similar emotional and sensory challenges. This article is a synthesis of the first author's experiences of DBT as an autistic person and professional insights from all authors. We provide an overview of the development of DBT, its foundational components, and adaptations. Using this basis, the first author describes the benefits DBT has had, the modifications that have helped him, and how those modifications may enhance DBT for autistic people. Modifications include visuals, graphics, and a gaming format that target the client's personal interests. The essence of these alterations is to transform life skills and DBT skills into something meaningful and functional. Receptivity of the therapist to the modifications and neurodivergent problem solving may be foundational to therapeutic success. Client-initiated contributions in collaborative therapy may improve autistic participants' understanding, validation, and adherence with DBT. The authors suggest expanding work on DBT modifications for autism in the areas of daily self-monitoring, assessing for preferred visual and gaming formats, and utilizing personal interests.

Why is this topic important?: Many autistic people struggle with their emotions. There are few therapies that assist autistic people with these challenges. Dialectical behavior therapy (DBT) is a therapy that teaches skills for coping with emotions and forming healthy bonds with others. DBT may provide benefits to autistic people. What is the purpose of this article?: This article uses personal insights with DBT from the first author. The article combines the professional expertise of all authors. We talk about the strengths DBT may have for autistic people. We recommend changes to make DBT a more helpful therapy. What personal or professional perspectives do the authors bring to this topic?: The first author is an autistic researcher in psychology. He has other mental health disabilities. He has been in DBT. The second author is an autistic person working in autism research and advocacy. The remaining authors are non-autistic. They do research and therapy with autistic people. What is already known about this topic?: DBT is used to help people manage their emotions and engage with others successfully. Many autistic people struggle with these skills. There is not a lot of research on how DBT can benefit autistic people. Early work has shown that it might be effective for autistic people. What do the authors recommend?: We outline several changes to DBT that might make it more helpful to autistic people. One change included is using images to help autistic people keep track of therapy skills. Another suggested change is making therapy into a game. More research is needed to test if these changes work in larger groups of autistic people. How will these recommendations help autistic adults now or in the future?: We hope therapists use these changes to DBT to better support autistic people. We hope that this encourages more research into how DBT can better help autistic people. Autistic people may also benefit from DBT skills in their own lives.

Abbreviated Dialectical Behavior Therapy Virtual Skills Group for Caregivers of Adolescents: An Exploratory Study of Service User and Clinical Outcomes.

Prior work emphasizes involving caregivers in youth mental health services. To support youth with emotion dysregulation, dialectical behavior therapy for adolescents (DBT-A) includes a multi-family skills group, wherein adolescents and caregivers learn skills together. However, limited work has examined the impact of caregiver involvement within DBT-A. The current study examines outcomes of two caregiver-only DBT-A skills groups adapted for abbreviated telehealth delivery. We report on caregivers' (N = 11, 100% mothers, 55% Hispanic) service user outcomes (e.g. self-efficacy at skill usage, group cohesion, therapeutic alliance) and clinical outcomes (i.e. their own emotion functioning, criticism, responses to their adolescent's negative emotions). Results indicate caregiver-only groups were feasible and acceptable, and suggest preliminary efficacy, including improvements in caregiver emotion functioning, distress during interactions with their adolescents, and adolescent-reported criticism. Caregivers also reported reductions in unsupportive responses with their adolescents. Overall, while we caution interpretation due to a small sample size, findings support the preliminary feasibility and efficacy of modifying caregiver participation in DBT-A to be less time-consuming and administered via telehealth.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy.

OBJECTIVE: To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST). METHOD: Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts. RESULTS: Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals. CONCLUSION: Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA. DIVERSITY & INCLUSION STATEMENT: We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. CLINICAL TRIAL REGISTRATION INFORMATION: Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www. CLINICALTRIALS: gov/; NCT01528020.

Efficacy of Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder: A Systematic Review of Randomized Controlled Trials.

Objective: Borderline personality disorder (BPD) is a serious public health problem. Dialectical Behavior Therapy (DBT) is a program that has provided encouraging results for its treatment. However, scientific evidence about its efficacy is scarce. Therefore, we aimed to describe the scientific production on the components of the DBT program and its therapeutic efficacy in the treatment of people with BPD. Method : A systematic review with relevant keywords was conducted based on studies available in Scopus, Web of Science, and PubMed until June 2023, including studies in English, research on therapeutic intervention, studies with a randomized controlled trial (RCT) design that included people with the diagnosis of BPD. Results: We found 18 RCTs, most of which supported the effectiveness of DBT for BPD. There were a total of 1,755 participants in these studies, most of whom were women. These studies looked for treating self-injurious behaviors, suicidal thoughts or ideations, number of visits to emergency services, and frequency of hospital admissions. Most studies revealed that both short-term DBT and standard DBT improved suicidality in BPD patients with small or moderate effect sizes, lasting up to 24 months after the treatment period. Furthermore, these studies showed that DBT can significantly improve general psychopathology and depressive symptoms in patients with BPD. Improvement of compliance, impulsivity, mood instability, as well as reduction in hospitalization rate are other findings observed in the trials following DBT. Conclusion: Although DBT shows efficacy in the treatment of BPD, heterogeneity in the methodologies employed is highlighted. Therefore, it is necessary to design studies from a homogeneous theoretical and methodological framework.

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.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies.

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Shame, suicidal ideation, and urges for non-suicidal self-injury among individuals with borderline personality disorder receiving dialectical behavior therapy: The mediating role of anger.

INTRODUCTION: Borderline personality disorder (BPD) is a disorder of pervasive emotion dysregulation associated with high rates of self-injurious thoughts and behaviors (SITB). Understanding specific emotion states in relation to SITB is important for effective intervention. METHODS: The current study examined whether, and how, the specific emotion of shame contributes to suicide ideation and urges to engage in non-suicidal self-injury (NSSI) both directly, and indirectly via anger, among individuals with BPD. Participants (N = 100) were enrolled in a 6-month comprehensive dialectical behavior therapy (DBT) program and provided daily ratings of shame, anger, suicide ideation, and urges for NSSI. RESULTS: We found that higher daily ratings of shame and anger were directly associated with higher same-day ratings of both suicidal ideation and urges for NSSI. Furthermore, anger partially mediated the relationships between shame and both suicidal ideation and urges for NSSI. CONCLUSION: These findings highlight shame and anger as potential antecedents of SITB among individuals with BPD. Clinical approaches, such as DBT, that include personalized, ongoing, clinical assessment of these specific affective states may be particularly important for treatment of SITB.

Learning from Adolescents and Caregivers to Enhance Acceptability and Engagement Within Virtual Dialectical Behavior Therapy for Adolescents Skills Groups: A Qualitative Study.

Despite the significant increase in adolescent mental health challenges in recent years, structural barriers continue to limit access to and engagement in mental health services. As such, opportunities to learn directly from adolescents and their families on how to best structure and deliver services are paramount. The current study assumes a multi-informant approach and reports on adolescents' and caregivers' (N = 33) experiences in an adapted telehealth/hybrid Dialectical Behavior Therapy for Adolescents (DBT-A) program. Focus groups were conducted across two cohorts of families who participated in DBT-A skills groups, to collect family-centered data on the acceptability of program modifications, engagement in the adapted telehealth/hybrid DBT-A, and recommendations for improvement. Participants were predominately Latine White and were from a broad range of socioeconomic backgrounds. Additionally, 45.5% of the adolescents identified as LGBTQ + . Focus group findings emphasized how the telehealth platform was both convenient and disengaging, and how in-person sessions offered improved group connection and content engagement. Participants underscored the importance of balancing multi-family group sessions with adolescent- and caregiver-only group sessions in the program, and adolescents emphasized a need for the DBT-A program to better center adolescents' unique experiences and voices throughout sessions. Both adolescents and caregivers suggested modifications to synthesize the content and improve generalizability of the DBT-A skills to their real lives. Overall, these findings add to a new and evolving branch of DBT-A qualitative inquiry, as well as the growing body of work that recommends incorporating the voices of people with lived experiences into the development and modification of psychological services.

Expanding considerations for treating avoidant/restrictive food intake disorder at a higher level of care.

Existing descriptions of the treatment of avoidant/restrictive food intake disorder (ARFID) at higher levels of care (HLOC) for eating disorders are limited, despite HLOC settings frequently serving patients with ARFID. The purpose of this commentary is to expand on the preliminary literature that describes pediatric ARFID treatment at HLOC by describing two specific components of our approach to treating pediatric ARFID that may not yet have traction in the current literature. Specifically, we highlight the utility of (1) treatment accommodations that appropriately account for patients' neurodevelopmental needs (e.g., executive functioning, sensory processing) and (2) the adjunctive use of Dialectical Behavior Therapy (DBT) elements within family-based pediatric ARFID treatment. We also describe necessary future directions for research in these domains to clarify if incorporating these considerations and approaches into pediatric ARFID treatment at HLOC does indeed improve treatment outcomes.

Momentary skills use predicts decreased binge eating and purging early in day treatment: An ecological momentary assessment study.

OBJECTIVE: Emerging research indicates that skills acquisition may be important to behavior change in cognitive behavior therapy (CBT) for eating disorders. This study investigated whether skills use assessed in real time during the initial 4 weeks of CBT-based day treatment was associated with momentary eating disorder behavior change and rapid response to treatment. METHODS: Participants with DSM-5 bulimia nervosa or purging disorder (N = 58) completed ecological momentary assessments (EMA) several times daily for the first 28 days of treatment. EMA assessed skills use, the occurrence of binge eating and/or purging, and state negative affect. Rapid response was defined as abstinence from binge eating and/or purging in the first 4 weeks of treatment. RESULTS: Greater real-time skills use overall, and use of "planning ahead," "distraction," "social support," and "mechanical eating" skills in particular, were associated with a lower likelihood of engaging in binge eating or purging during the same period. After controlling for baseline group differences in overall difficulties with emotion regulation, rapid and non-rapid responders did not differ in overall skills use, or skills use at times of higher negative affect, during the EMA period. DISCUSSION: Momentary use of skills appears to play an important role in preventing binge eating and purging, and certain skills appear to be particularly helpful. These findings contribute to the literature elucidating the processes by which CBT treatments for eating disorders work by providing empirical evidence that skills use helps to prevent binge eating and purging behaviors. PUBLIC SIGNIFICANCE: Individuals with eating disorders learn new skills during treatment to help them improve their symptoms. This study shows that for people with eating disorders, using skills helps prevent eating disorder behaviors in the moment. Certain skills may be particularly helpful, including planning ahead, distracting activities, support from others, and focusing on eating meals and snacks regardless of how one is feeling. These findings help us better understand how treatments work.

Dialectical Behavior and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder.

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

Comparison of the Effect of Dialectical Behavior Therapy, Acceptance and Commitment Therapy mindfulness-based Stress Reduction on Irritable Bowel Syndrome Symptoms, Quality of Life, Anxiety and Depression: A Pilot Randomized Controlled Trial.

This study aimed to compare dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT) and mindfulness based stress reduction (MBSR) effects on irritable bowel syndrome (IBS) symptoms, quality of life (QOL), anxiety and depression among patients with IBS. Eighty three eligible patients with a Rome- IV diagnosis were randomly allocated in DBT, MBSR, ACT, and control groups (n = 22 per group). All the patients were evaluated for IBS symptoms by IBS Severity Scoring System (IBS-SSS), QOL by irritable bowel syndrome quality of life (IBS-QOL), anxiety by Beck's Anxiety Inventory (BAI) and depression by Beck Depression Inventory- II (BDI-II) on the studied groups at the time of their inclusion in the study and 8 weeks after it. Each of the intervention groups took part in 8 group sessions. Conversely, the control group were evaluated without any intervention. 54 male and 29 female in 4 groups completed the study: DBT (n = 20), MBSR (n = 19), ACT (n = 22), and control groups (n = 22). The results showed significant differences between the groups based on the variables of the IBS-SSS, IBS-QOL, BAI and BDI-II (p < 0.05). Furthermore, the ACT intervention had considerably lower levels of IBS symptoms, anxiety, and depression compared to the other groups; also, the significant impacts of the QOL variable showed the higher scores of the ACT compared to the treatment groups. The therapies could not be applied to other groups of people. Other shortcomings were the absence of a follow-up strategy. This research offers preliminary evidence that ACT is more successful than other therapy groups in reducing IBS symptoms, anxiety and sadness, and improving QOL in IBS patients.