A machine-learning approach for differentiating borderline personality disorder from community participants with brain-wide functional connectivity.

BACKGROUND: Functional connectivity has garnered interest as a potential biomarker of psychiatric disorders including borderline personality disorder (BPD). However, small sample sizes and lack of within-study replications have led to divergent findings with no clear spatial foci. AIMS: Evaluate discriminative performance and generalizability of functional connectivity markers for BPD. METHOD: Whole-brain fMRI resting state functional connectivity in matched subsamples of 116 BPD and 72 control individuals defined by three grouping strategies. We predicted BPD status using classifiers with repeated cross-validation based on multiscale functional connectivity within and between regions of interest (ROIs) covering the whole brain-global ROI-based network, seed-based ROI-connectivity, functional consistency, and voxel-to-voxel connectivity-and evaluated the generalizability of the classification in the left-out portion of non-matched data. RESULTS: Full-brain connectivity allowed classification (∼70 %) of BPD patients vs. controls in matched inner cross-validation. The classification remained significant when applied to unmatched out-of-sample data (∼61-70 %). Highest seed-based accuracies were in a similar range to global accuracies (∼70-75 %), but spatially more specific. The most discriminative seed regions included midline, temporal and somatomotor regions. Univariate connectivity values were not predictive of BPD after multiple comparison corrections, but weak local effects coincided with the most discriminative seed-ROIs. Highest accuracies were achieved with a full clinical interview while self-report results remained at chance level. LIMITATIONS: The accuracies vary considerably between random sub-samples of the population, global signal and covariates limiting the practical applicability. CONCLUSIONS: Spatially distributed functional connectivity patterns are moderately predictive of BPD despite heterogeneity of the patient population.

The Psychological Emptiness Scale: a psychometric evaluation.

BACKGROUND: Feelings of emptiness are commonly reported as deeply distressing experiences. Despite established relationships between emptiness and many mental health difficulties, alongside self-harm and suicide, further study into this phenomenon has been restricted by vague definition and clinical measures with limited utility. Recently the first definition validated by individuals with lived experience of emptiness has been conceptualised, providing an opportunity to create a new measure of emptiness. AIMS: This study aimed to psychometrically evaluate the 31-item Psychological Emptiness Scale (PES), identifying redundancy, and thus creating a psychometrically robust scale with optimised clinical utility. METHOD: Utilising an online survey design, 768 participants completed the 31 items of the initial PES alongside other measures of mental health. Exploratory factor analysis was conducted, and item response theory employed to identify item redundancy and reduce test burden. Expert clinicians provided ratings of each item's clinical relevance and, combined with the psychometric analysis, led to the removal of a number of items. Confirmatory factor analysis was then undertaken. Reliability including test-retest, validity and sensitivity of the measure were evaluated. RESULTS: A two-factor structure encompassing 'nothingness' and 'detachment' was identified, and found to have acceptable fit. The resulting 19-item PES was found to have internal consistency (α = 0.95), convergent validity and test-retest reliability. CONCLUSIONS: This study demonstrated strong psychometric properties of the PES. The PES has potential to support research into the role of emptiness in psychological distress and treatment in clinical practice.

The mediating role of attachment and mentalising in the relationship between childhood maltreatment, self-harm and suicidality.

BACKGROUND: Although the relationship between childhood maltreatment, self-harm and suicidality is well-established, less is known about the mediating mechanisms explaining it. Based on a developmental mentalisation-based theoretical framework, childhood adversity compromises mentalising ability and attachment security, which in turn increase vulnerability to later stressors in adulthood. OBJECTIVE: This study aimed to investigate the role of attachment and mentalising as potential mechanisms in the relationship between childhood maltreatment, self-harm and suicidality. PARTICIPANTS AND SETTING: We recruited 907 adults from clinical and community settings in Greater London. METHODS: The study design was cross-sectional. Participants completed self-report questionnaires on retrospectively rated childhood trauma, and current attachment to the romantic partner, mentalising, self-harm, suicidal ideation and attempt. We used structural equation modelling to examine the data and conceptualized childhood maltreatment as a general factor in a confirmatory bifactor model. RESULTS: The results showed that childhood maltreatment was both directly associated with self-harm and suicidality and indirectly via the pathways of attachment and mentalising. CONCLUSIONS: These findings indicate that insecure attachment and impaired mentalising partially explain the association between childhood maltreatment, self-harm and suicidality. Clinically, they provide support for the potential of mentalisation-based therapy or other psychosocial interventions that aim to mitigate the risk of self-harm and suicidality among individuals who have experienced childhood maltreatment via increasing understanding of self and other mental states.

Impaired mentalizing in depression and the effects of borderline personality disorder on this relationship.

BACKGROUND: Mentalizing, the ability to understand the self and others as well as behaviour in terms of intentional mental states, is impaired in Borderline Personality Disorder (BPD). Evidence for mentalizing deficits in other mental disorders, such as depression, is less robust and these links have never been explored while accounting for the effects of BPD on mentalizing. Additionally, it is unknown whether BPD symptoms might moderate any relationship between depressive symptoms and mentalizing. METHODS: Using multivariate regression modelling on cross-sectional data obtained from a sample of 274 participants recruited from clinical settings, we investigated the association between mentalizing impairment and depression and examined whether this was moderated by the presence and number of concurrent BPD symptoms, while adjusting for socio-demographic confounders. RESULTS: Impaired mentalizing was associated with depressive symptoms, after adjustment for socio-demographic confounders and BPD symptoms (p = 0.002, ß = - 0.18). BPD symptoms significantly moderated the association between impaired mentalizing and depressive symptoms (p = 0.003), with more severe borderline symptoms associated with a stronger effect of poor mentalization on increased depressive symptoms. CONCLUSION: Mentalizing impairments occur in depression even after adjusting for the effect of BPD symptoms. Our findings help further characterise mentalizing impairments in depression, as well as the moderating effect of BPD symptoms on this association.. Further longitudinal work is required to investigate the direction of association.

Probing commitment in individuals with borderline personality disorder.

Interpersonal problems are a core symptom of borderline personality disorder (BPD). In particular, patients with BPD exhibit a heightened sensitivity to cues of acceptance or rejection in their relationships. The current study investigated the psychological processes underpinning this heightened responsiveness. In a between-subjects design, we implemented a reactivity induction designed to trigger either acceptance or rejection of a partner in two separate groups, and measured the effects which this manipulation had upon 49 patients with BPD, as well as 52 control participants. The experimental paradigm required participants to repeatedly choose whether to coordinate with their partner on a decision-making task. When both players coordinate on the same option, both are rewarded. The experiment probed participants' commitment to their partners: participants were sometimes presented with tempting opportunities to unilaterally defect from the coordination. The results show that participants in the BPD group were less committed than participants in the control group when exposed to the rejection manipulation.

Multidirectional Pathways between Attachment, Mentalizing, and Posttraumatic Stress Symptomatology in the Context of Childhood Trauma.

INTRODUCTION: Exposure to traumatic stressful events in childhood is an important risk factor for the development of posttraumatic symptomatology. From a mentalization-based developmental perspective, childhood adversity can affect attachment in children and may result in insecure attachment and impaired mentalizing abilities, which increase the lifetime risk for psychopathology. The present cross-sectional study examined the potential mediating role of attachment insecurity and impaired mentalizing on the relationship between childhood trauma and posttraumatic symptomatology. METHOD: Adults who had experienced childhood neglect and abuse (n = 295, 184 patients with personality disorder and 111 community controls) completed self-report measures of posttraumatic stress disorder (PTSD) symptoms, dissociative experiences, adult attachment insecurity, and mentalizing. RESULTS: Structural equation modelling results revealed that attachment insecurity together with lower mentalizing mediated the link between childhood trauma and PTSD symptoms, and lower mentalizing mediated the link between childhood trauma and dissociative experiences. CONCLUSION: The findings show that attachment insecurity and lower mentalizing play significant mediating roles in the reporting of posttraumatic symptomatology among survivors of childhood abuse and neglect, with treatment implications for mentalization-based therapy as beneficial for individuals with a history of childhood trauma.

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.

The development and theoretical application of an implementation framework for dialectical behaviour therapy: a critical literature review.

BACKGROUND: Dialectical behaviour therapy (DBT) is a third wave behaviour therapy combining behaviour based components with elements of mindfulness. Although DBT effectiveness has been explored, relatively little attention has been given to its implementation. Frameworks are often the basis for gathering information about implementation and can also direct how the implementation of an intervention is conducted. Using existing implementation frameworks, this critical literature review scoped the DBT implementation literature to develop and refine a bespoke DBT implementation framework. METHOD AND RESULTS: The initial framework was developed by consolidating existing implementation frameworks and published guidance on DBT implementation. The critical literature review retrieved papers from Medline, CINAHL, PsycInfo, PubMed, and the reference lists of included papers. Framework elements were used as codes which were applied to the literature and guided the synthesis. Findings from the synthesis refined the framework.The critical literature review retrieved 60 papers but only 14 of these explicitly focused on implementation. The DBT implementation framework captured all the execution barriers and facilitators described in the literature. However, the evidence synthesis led to a more parsimonious framework as some elements (e.g., research and published guidance) were seldom discussed in DBT implementation. CONCLUSION: To our knowledge this is the first published review exploring DBT implementation. The literature synthesis suggests some tentative recommendations which warrant further exploration. For instance, if DBT implementation is not pre-planned, having someone in the organisation who champions DBT can be advantageous. However, as the literature is limited and has methodological limitations, further prospective studies of DBT implementation are needed.

Abuse, invalidation, and lack of early warmth show distinct relationships with self-criticism, self-compassion, and fear of self-compassion in personality disorder.

BACKGROUND: Cultivating self-compassion is increasingly recognized as a powerful method to regulate hyperactive threat processes such as shame and self-criticism, but fear of self-compassion (FSC) can inhibit this. These difficulties are underexplored in personality disorder (PD) despite their prevalence. Furthermore, little evidence exists regarding how these factors relate to adverse childhood experiences (ACEs) and attachment. METHOD: Fifty-three participants with a diagnosis of PD completed measures including childhood abuse/neglect, invalidation, early warmth, self-compassion, shame, self-criticism, FSC, and anxious/avoidant attachment. RESULTS: Self-compassion was predicted uniquely by low early warmth; self-inadequacy by invalidation and abuse; and FSC by multiple ACEs. FSC and self-compassion were significantly correlated with self-criticism and shame, but not with one another. CONCLUSIONS: Low self-compassion and high FSC appear to be distinct problems, substantiating physiological models proposing distinct threat and soothing systems. Results are consistent with theories positing that low self-compassion has distinct origins to shame, self-criticism, and FSC.

Inhibitors and facilitators of compassion-focused imagery in personality disorder.

BACKGROUND: Compassion-focused therapy (CFT) has potential to benefit clients with a personality disorder (PD), given the inflated levels of shame and self-criticism in this population. However, clinical observation indicates that clients with PD may find techniques from this approach challenging. AIMS: The aim of this study is to trial one aspect of CFT, compassion-focused imagery (CFI), with this population, and identify factors that predict clients' ability to generate CFI and experience self-compassion during the task, including type of CFI exercise and, second, to establish whether CFI outcomes increase with practice. METHOD: In Study 1, 53 participants with a diagnosis of PD completed measures of self-compassion, self-reassurance, shame, self-criticism, fear of self-compassion, affect, anxious and avoidant attachment, and mental imagery abilities. Participants were assigned to trial CFI from memory (n = 25) or from imagination (n = 28), then rated their image's vividness, its compassionate traits, and ease of experiencing compassion. A negative mood manipulation was carried out, and CFI tasks and outcome measures were repeated. For Study 2, self-compassion and self-criticism were measured before and after 1 week of daily CFI practice. RESULTS: Study 1 found that negative mood and low mental imagery ability are significant inhibitors to generating compassionate images and affect. The 2 CFI exercises were equally effective. Study 2 suffered from high attrition, but regular practice was associated with significant improvement in self-compassion (though not self-criticism). CONCLUSIONS: CFI appears to be effective in improving self-compassion for some clients. However, it is less effective in the presence of negative affect. Clients with low mental imagery ability may benefit more from alternative CFT techniques.

Offenders With Antisocial Personality Disorder Display More Impairments in Mentalizing.

This study was designed to test the hypothesis that individuals with antisocial, particularly violent, histories of offending behavior have specific problems in social cognition, notably in relation to accurately envisioning mental states. Eighty-three male offenders on community license, 65% of whom met the threshold for antisocial personality disorder (ASPD), completed a battery of computerized mentalizing tests requiring perspective taking (Perspectives Taking Test), mental state recognition from facial expression (Reading the Mind in the Eyes Test), and identification of mental states in the context of social interaction (Movie for the Assessment of Social Cognition). The results were compared with a partially matched sample of 42 nonoffending controls. The offender group showed impaired mentalizing on all of the tasks when compared with the control group for this study when controlling for demographic and clinical variables, and the offending group performed poorly in comparisons with participants in published studies, suggesting that limited capacity to mentalize may be part of the picture presented by individuals with histories of offending behavior. Offenders with ASPD demonstrated greater difficulty with mentalizing than non-ASPD offenders. Mentalization subscales were able to predict offender status and those with ASPD, indicating that specific impairments in perspective taking, social cognition, and social sensitivity, as well as tendencies toward hypomentalizing and nonmentalizing, are more marked in individuals who meet criteria for a diagnosis of ASPD. Awareness of these deficits may be helpful to professionals working with offenders, and specifically addressing these deficits may be a productive aspect of therapy for this "hard to reach" clinical group.

A real-world study of the effectiveness of DBT in the UK National Health Service.

OBJECTIVES: Dialectical behavioral therapy (DBT) has gained widespread popularity as a treatment for borderline personality disorder (BPD), and its efficacy has been demonstrated in several trials. The aim of this study was to evaluate the effectiveness of DBT delivered by staff with a level of training readily achievable in National Health Service care settings for individuals with a Cluster B personality disorder. DESIGN: Randomized control trial methodology was used to compare DBT to treatment as usual (TAU). METHOD: Forty-two participants entered the trial. Diagnostic and outcome measures were undertaken at assessment, at 6 months, and at 1 year. The clinical outcomes in routine evaluation--outcome measure (CORE-OM) were utilized as the primary outcome measure. RESULTS: Both the DBT and TAU groups improved on the range of measures employed. The DBT group showed a slightly greater decrease in CORE-OM risk scores, suicidality, and post-traumatic stress disorder symptom severity. However, the TAU group showed comparable reductions in all measures and a larger decrease in para-suicidal behaviours and risk. CONCLUSIONS: DBT may be an effective treatment delivered by community outpatient services for individuals with a Cluster B personality disorder. Further studies are needed to consider the impact of experience and adherence to DBT in improving outcome.

A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality disorder.

OBJECTIVES: Mindfulness-based cognitive therapy (MBCT) was originally developed to prevent relapse in recurrent depression. More recently it has been applied to individuals at high risk of suicide or currently suffering with anxiety and depression. The aim of this study was to consider the feasibility of MBCT for individuals with a diagnosis of borderline personality disorder (BPD). DESIGN: The design of the study was a repeated measures, quasi-experimental design employing within-subject and between-subject comparisons of a sample of participants with BPD. Based on previous studies and theoretical models of the effect of mindfulness and of cognitive therapy, pre- and post-group measures of mindfulness, depression, anxiety, dissociation, impulsivity, experiential avoidance, and attention were obtained. METHOD: Participants attended an 8-week adapted MBCT (MBCT-a) group intervention. A total of 22 participants were assessed pre- and post-intervention and were subsequently divided for analysis into two groups: treatment completers (N= 16) and non-completers (number of sessions attended < 4; N= 6). RESULTS: The study found that MBCT-a is acceptable to individuals with BPD. Using intention to treat analyses, only attentional control improved. However, post hoc analyses of treatment improvers (N= 9) identified changes in mindfulness and somatoform dissociation. A dose-effect analysis suggested a weak improvement in mindfulness, experiential avoidance, state anxiety, and somatoform dissociation. CONCLUSIONS: This study suggests that further exploration of MBCT for use with individuals with BPD is merited. The study lends tentative support for attentional and avoidance models of the effects of mindfulness.

The long-term impact of war experiences and evacuation on people who were children during World War Two.

During World War Two 1.9 million people were evacuated from British cities where the risk of bombing was perceived to be highest. 1.5 million of these were children who, often unaccompanied, were sent to live with strangers. Two hundred and forty-five people who were evacuated as children were compared with 96 of similar age who did not experience evacuation. Within this self-selected sample, significant numbers of the evacuees were found to have experienced abuse and neglect. Pre-evacuation abuse made continued abuse likely during evacuation, while abuse during evacuation led to children being more likely to continue to be abused on their return home. Abuse during evacuation led to increased scores on the Impact of Event Scale and General Health Questionnaire, and to insecure attachment patterns. The role of evacuation and abuse in the maintenance of long-term psychological problems is discussed.

Allocentric versus egocentric spatial memory after unilateral temporal lobectomy in humans.

Thirty patients who had undergone either a right or left unilateral temporal lobectomy (14 RTL; 16 LTL) and 16 control participants were tested on a computerized human analogue of the Morris Water Maze. The procedure was designed to compare allocentric and egocentric spatial memory. In the allocentric condition, participants searched for a target location on the screen, guided by object cues. Between trials, participants had to walk around the screen, which disrupted egocentric memory representation. In the egocentric condition, participants remained in the same position, but the object cues were shifted between searches to prevent them from using allocentric memory. Only the RTL group was impaired on the allocentric condition, and neither the LTL nor RTL group was impaired on additional tests of spatial working memory or spatial manipulation. The results support the notion that the right anterior temporal lobe stores long-term allocentric spatial memories.