Transcutaneous auricular vagus nerve stimulation to acutely reduce emotional vulnerability and improve emotional regulation in borderline personality disorder (tVNS-BPD): study protocol for a randomized, single-blind, sham-controlled trial.

BACKGROUND: Borderline personality disorder (BPD) is considered a disorder of emotion regulation resulting from the expression of a biologically determined emotional vulnerability (that is, heightened sensitivity to emotion, increased emotional intensity/reactivity, and a slow return to emotional baseline) combined with exposure to invalidating environments. Vagal tone has been associated with activity in cortical regions involved in emotion regulation and a lower resting state of vagal tone has been observed in BPD patients relative to healthy controls. Non-invasive transcutaneous auricular vagus nerve stimulation (taVNS) has been shown to reduce temper outbursts in adults with Prader-Willi Syndrome, to enhance recognition of emotions in healthy students, and to improve depressive and anxiety symptoms. Furthermore, a single session of taVNS has been shown to acutely alter the recognition of facial expressions of negative valence in adolescents with MDD and increase emotion recognition in controls. However, the effect of taVNS on emotional vulnerability and regulation in individuals diagnosed with BPD has not been investigated. Our aims are to determine if taVNS is effective in acutely reducing emotional vulnerability and improve emotional regulation in BPD patients. METHODS: Forty-two patients will be randomized to a single session of taVNS or sham-taVNS while going through an affect induction procedure. It will consist of the presentation of one neutral and three negative affect-evoking 4-min-long videos in sequence, each of which is followed by a 4-min post-induction period during which participants will rate the quality and intensity of their current self-reported emotions (post-induction ratings) and the perceived effectiveness in managing their emotions during the video presentation. The rating of the current self-reported emotions will be repeated after every post-induction period (recovery ratings). Mixed models with individuals as random effect will be used to investigate the ratings at each stage of the study, taking into account the repeated measures of the same individuals at baseline, pre-induction, post-induction, and recovery. DISCUSSION: The study has potential to yield new insights into the role of vagal tone in emotion dysregulation in BPD and offer preliminary data on the effectiveness of taVNS as a possible non-invasive brain stimulation to treat a core symptom of BPD. TRIAL REGISTRATION: ClinicalTrials.gov NCT05892900. Retrospectively registered on Jun 07, 2023.

Life experienced as worth living and beyond: a qualitative study of the pathways to recovery and flourishing amongst individuals treated for borderline personality disorder.

BACKGROUND: Dialectical Behaviour Therapy (DBT) is recognized as a leading evidence-based treatment, effective in reducing symptoms of borderline personality disorder (BPD), as well as co-occurring clinical syndromes. However, symptom remission may not be the same as a life experienced as worth living. The purpose of the study was to understand, from the perspective of individuals with lived experience, the concepts of recovery, life experienced as worth living and flourishing after treatment for BPD, and to describe the pathways to wellness after symptom remission. METHODS: Semi-structured interviews were conducted with nine adult women previously diagnosed with BPD, co-occurring clinical syndromes and severe self-harm behaviour who self-identified as recovered for a minimum of two years, recruited from a network for individuals with lived experience. The average duration of recovery was 5.7 years with a range from 2 to 10 + years. Data were analysed using thematic analysis. RESULTS: Four main themes and 14 subthemes were generated from our analyses. Main themes indicated that loved ones helped recovery and to create a life worth living, that participants identified as recovered and as healthy and beyond, and that becoming well is a long process associated in part with reclaiming a healthy identity. Participants defined recovery as separate but related to a life worth living, which in turn was separate but related to being healthy and having lives they described as being beyond health and well-being. The wellness process was described as lengthy and non-linear, including setbacks that with time no longer derailed daily life. A proposed theoretical model depicting the wellness process over time from symptom remission to the experience of a life beyond health and wellness is presented. CONCLUSIONS: This qualitative study contributes knowledge of what a life experienced as worth living means, as well as how wellness progressed into flourishing for some participants within a sample of individuals with lived experience. Our findings may inform treatment development that targets more than symptom reduction, which in turn may shorten trajectories from symptom remission to health, wellness, and flourishing.

School-based self-harm prevention programs: A systematic review with implications for international implementation.

Both self-harm and suicidal behaviors have been targeted through school-based prevention programs, many of which have been developed in the United States. The aims of this systematic review were to assess effects of school-based prevention programs on suicide and self-harm and to evaluate whether they are fit to the exporting culture. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our inclusion criteria, structured according to population/problem, intervention, control/comparison, outome, were: children and youth up to 19 years of age, school-based programs at universal, selective or indicated levels compared with teaching as usual or with other programs, and outcomes of suicide or self-harm measured at least 10 weeks after intervention. Studies without a control group or using non-behavioral outcomes were excluded. A comprehensive and systematic literature search was conducted from the 1990s to March 2022. Risk for bias was assessed with checklists adapted from the Cochrane Risk of Bias (ROB) tool. A total of 1,801 abstracts were retrieved. Five studies fulfilled our inclusion criteria, but one had high risk for bias. Confidence in the evidence for effect was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Studies included in this review were evaluated with respect to applicability in the context of international export. Only two school-based programs demonstrated efficacy in preventing suicidal behaviors. Although implementation of evidence-based interventions is a crucial next step, further replication with simultaneous attention to dissemination and implementation issues are called for. Funding and registration: conducted on assignment by the Swedish government. The protocol is available at the SBU website in Swedish.

The five self-harm behavior groupings measure: empirical and thematic data from a novel comprehensive self-harm assessment.

Introduction: The Five Self-Harm Behavior Groupings Measure (5S-HM) is a novel assessment that evaluates behaviours which may go undetected by existing measures. Self-harm is formulated across directness and lethality spectra, including under-studied behaviors such as indirect self-harm, harmful self-neglect and sexual self-harm. Aims of the study were to: (1) empirically evaluate the 5S-HM; (2) to determine whether the 5S-HM generates relevant new information with respect to the forms and functions given by participants for self-harm within a clinical sample; (3) to test the utility and novel contributions of the Unified Model of Self-Harm and the 5S-HM by extension. Methods: Data were collected from N = 199 individuals (Mage = 29.98, SD = 8.41, 86.4% female), receiving specialized evidence-based treatments for self-harm, borderline personality disorder or eating disorders. Construct validity was determined via Spearman correlations, and internal consistency was established from Cronbach's alpha. Inductive thematic analysis was used to analyze and interpret qualitative data on reasons, forms and functions participants reported in relation to self-harm following Braun and Clarke's analytic guidelines. Thematic mapping was used to summarize qualitative data. Results: Test-retest reliability on a subsample of n = 24, tested 14 days after Time 1 was supported by a good intraclass correlation (0.68). Internal consistency (Cronbach's alpha = 0.75) was acceptable to good, as was construct validity comparing the 5S-HM total score to two validated self-harm measures (rho = 0.40, p < 0.01; rho = 0.26, p < 0.01). A thematic map depicting antecedents and consequences of self-harm over time suggests that self-harm is initiated by negative emotional states and self-intolerance. Novel findings in relation to sexual self-harm indicated that reasons for these behaviors were either to improve or worsen one's situation through being hurt by someone else. Discussion: The empirical analyses of the 5S-HM demonstrate that it is a robust measure for use in clinical and research settings. Thematic analyses proposed explanations for why self-harm behaviors are initiated and how they are reinforced over time. Sexual self-harm in particular requires further careful study.

What happens to young adults who have engaged in self-injurious behavior as adolescents? A 10-year follow-up.

This study examined the longitudinal associations between non-suicidal self-injury (NSSI) in early adolescence and various positive and negative aspects of mental health in young adulthood. The participants were a cohort of regular school students (n = 1064) in grades 7-8 from a Swedish municipality. Nine hundred and ninety-one of these completed an 11-page questionnaire (T1: Mage = 13.7; 50.3% girls); 1 year later, 984 students completed the questionnaire again (T2: Mage = 14.8; 51.1% girls); and 10 years later, 557 took part (T3: Mage = 25.3; 59.2% women). The prevalence of any NSSI (≥ 1 instance) decreased from about 40% in adolescence to 18.7% in young adulthood, while the prevalence of repetitive NSSI (≥ 5 instances) decreased from about 18 to 10%. Compared to individuals who reported no NSSI as adolescents, and controlling for gender and psychological difficulties in adolescence, adolescents with stable repetitive NSSI (i.e., repetitive NSSI at both T1 and T2) showed significantly higher levels of stress, anxiety, NSSI, and difficulties in emotion regulation 10 years later. Even infrequent and unstable repetitive NSSI in adolescence was associated with negative outcomes in young adulthood. These results suggest that stable repetitive NSSI in adolescence is a strong risk factor for mental health problems in young adulthood and that occasional engagement in NSSI in adolescence is an indicator of vulnerability for poorer mental health in young adulthood.

A Brief Breathing Space: Experiences of Brief Admission by Self-Referral for Self-Harming and Suicidal Individuals with a History of Extensive Psychiatric Inpatient Care.

Individuals with severe self-harm and experiences of lengthy psychiatric admissions often have complex mental health conditions and are at risk of suicide. In this qualitative study, self-harming individuals with >180 days of psychiatric admission over 12 months shared their experiences of Brief Admission (BA), a standardized crisis-management intervention encouraging self-admission and autonomy. Phenomenological hermeneutic analysis formulated BA as a worthy respite, replacing an old system of having to prove need 'in blood' or wait and get worse. Successes and struggles in early help-seeking, interpreted in the light of human rights and person-centered care, suggested that individual development of autonomy depended on perceived focus on recovery and compassion. Future research may consider ethical and health-economic aspects of BA in a broader perspective.

One-Year Consistency in Lifetime Frequency Estimates and Functions of Non-Suicidal Self-Injury in a Clinical Sample.

Non-suicidal self-injury (NSSI), the direct, deliberate destruction of one's own bodily tissue in the absence of an intent to die, is frequently used for evaluating treatment in clinical care. One instrument for assessing NSSI is the Inventory of Statements About Self-Injury (ISAS). The ISAS is a self-rating measure examining the lifetime frequencies of NSSI behaviors and further exploring NSSI functions. The study aimed to examine the consistency of self-reported lifetime NSSI frequencies and functions (via the ISAS) in a clinical sample of individuals with current self-harm and/or recurrent suicidal behaviors over one year. Fifty-two individuals (84.6% women) completed the ISAS three times over 1 year. We found relatively good test-retest stability for most NSSI behaviors and functions, but the correlation coefficients and frequencies of NSSI behaviors varied substantially. Approximately, 50% of participants reported lower lifetime frequencies of NSSI behaviors at the later time points, with approximately 20% reporting a significant reduction in their lifetime frequencies over one year. This unexpected finding raises concerns about the accuracy of reporting lifetime NSSI frequencies among individuals with multiple psychiatric diagnoses and extensive NSSI behaviors across their lives. Further research is needed to determine more reliable ways of collecting data on the lifetime frequency of NSSI in clinical samples and the accuracy of lifetime NSSI frequency estimates in general.

Family Connections in different settings and intensities for underserved and geographically isolated families: a non-randomised comparison study.

BACKGROUND: Family Connections (FC) is a multi-family skills training program for relatives of individuals with borderline personality disorder (BPD) and related difficulties, typically offered once per week for 12-14 weeks. Families with loved ones receiving residential Dialectical Behaviour Therapy DBT (DBT-R) in a different community, or those with multiple caregiving demands may have difficulty participating in weekly standard FC (FC-S). The aims of this paper are to: 1) Evaluate the results of the FC-S approach compared with an intensified weekend FC model developed for family members whose relatives are in DBT-R (FC-R); 2) Evaluate outcomes of FC-R for families with loved ones returning home from DBT-R, as little is known about how this population fares. METHODS: Data were collected at pre-treatment (T1), post-treatment (T2), and at six-to-seven-month follow-up (T3) in this non-randomized comparison study. A total of 82 family members participated, 34 of whom completed the FC-S program and 48 of whom completed the FC-R program. The evaluation was based upon outcomes derived from a standard battery used in FC research, analyzed by time and treatment setting. A composite score to evaluate family distress was generated. Two-way mixed multivariate analyses of variance (MANOVA) were employed to evaluate time (pre-versus-post versus follow-up) and group (FC-S versus FC-R). RESULTS: Scores on measures of mental health difficulties (General Severity Index), sense of burden (Burden Assessment Scale), and Global Family Functioning showed improvement over time. Having a loved one return home from DBT-R was associated with worsening on the GSI and the BAS at post-test. Notably, this deterioration was not found at follow-up. CONCLUSIONS: Little is known about families with loved ones receiving DBT-R other than the fact that their loved ones had not responded to previous services, which suggests greater complexity and chronicity. Because the family members receiving the weekend intensive FC-R version of FC demonstrated improvement, preliminary support exists for service providers to use the weekend intensive FC-R model as a time-and-cost efficient option whenever barriers exist to participating in weekly FC-S. Our findings also suggest that booster sessions may be indicated for families receiving loved ones home from DBT-R programs.

Effect of Brief Admission to Hospital by Self-referral for Individuals Who Self-harm and Are at Risk of Suicide: A Randomized Clinical Trial.

Importance: To our knowledge, there is no consensus regarding when individuals who repeatedly self-harm and are at risk of suicide should be hospitalized. To evaluate a new alternative, we examined the effects of brief admission (BA) to hospital by self-referral. Objectives: To determine the effects of BA on inpatient service use and on secondary outcomes of daily life functioning, nonsuicidal self-injuries, and attempted suicide among individuals who self-harm and are at risk of suicide. Design, Setting, and Participants: The single-masked Brief Admission Skåne Randomized Clinical Trial was conducted from September 2015 to June 2018 at 4 psychiatric health care facilities in southern Sweden. Data were collected 6 months retrospectively at baseline and at 6-month and 12-month follow-ups. Participants were randomized to either BA and treatment as usual (BA group) or treatment as usual (control group). The sample was a referral population, with the most important inclusion criteria being current episodes of self-harm and/or recurrent suicidality, at least 3 diagnostic criteria for borderline personality disorder, and hospitalization in the last 6 months. Interventions: Self-referred BA was offered for 12 months, with standard limits for duration and frequency, after the negotiation of a contract outlining the intervention. Main Outcomes and Measures: Prespecified main outcome measures were days admitted to the hospital, including voluntary admission, BA, and compulsory admission. Results: The 125 participants had a mean (SD) age of 32.0 (9.4) years, 106 (84.8%) were women, and 63 were randomized to the BA group and 62 to the control group. No significant advantage was observed in the number of days in the hospital for the BA group compared with the control group. Within-group analyses demonstrated significant decreases in both groups regarding days admitted to the hospital (BA group: χ2 = 22.71; P < .001; control group: χ2 = 23.01; P < .001) and visits to the emergency department (BA group: χ2 = 13.95; P < .001; control group: χ2 = 21.61; P < .001), but only the BA group showed a reduction in days with compulsory admission (χ2 = 7.67; P = .02) and nonsuicidal self-injuries (χ2 = 6.13; P = .047). The BA group showed significantly greater improvements in the mobility domain of daily life functioning (z = -2.39; P = .02) and significant within-group improvements in 3 other domains (cognition: F = 9.02; P < .001; domestic responsibilities: F = 3.23; P = .049; and participation: F = 3.79; P = .03). Conclusions and Relevance: Brief admission appears no more efficacious in reducing use of inpatient services than usual care for individuals who self-harm and are at risk of suicide. Future studies should explore other possible beneficial effects. Trial Registration: ClinicalTrials.gov identifier: NCT02985047.

Predictable, Collaborative and Safe: Healthcare Provider Experiences of Introducing Brief Admissions by Self-referral for Self-harming and Suicidal Persons with a History of Extensive Psychiatric Inpatient Care.

People with severe self-harming behavior and histories of lengthy psychiatric inpatient admissions can represent a challenge to care providers. This interview-based study illuminates healthcare provider experiences (n = 12) of Brief Admission (BA) among self-harming individuals, with >180 days of psychiatric admission the previous year. Qualitative content analysis revealed that providers experienced benefits of increased predictability, and a shift from trigger and conflict to collaboration with individuals admitted to BA. Staff participants expressed an increased sense of safety and a strengthened link between inpatient and outpatient caregiving. Results indicated that BA is a promising intervention for self-harming individuals with extensive psychiatric histories.

Preliminary evaluation of an intensive integrated individual and family therapy model for self-harming adolescents.

BACKGROUND: To investigate the outcome of an integrated individual and family therapy (Intensive Contextual Treatment: ICT) in terms of reducing suffering and increasing functional adjustment among self-harming and/or suicidal adolescents with high symptom loads and their families. METHODS: Forty-nine self-harming and/or suicidal adolescents, Mage = 14.6, of predominantly Swedish origin and female gender (85.7%) participated with their parents. The study had a within group design with repeated measures at pre- and post-treatment, as well as six- and twelve-months follow-ups. Self-reports were used for the main outcomes; self-harm rates, suicide attempts, parent-reported days of inpatient/institutional care, internalized and externalized symptoms, perceived stress, emotion regulation, school hours and adjustment. Secondary outcomes were levels of reported expressed emotions within family dyads, as well as parental anxiety, depression and stress. RESULTS: From pre- to post-assessment, the adolescents reported significant reductions of self-harm (p = .001, d = 0.54) and suicide attempts (p < .0001, d = 1.38). Parent-reported days of inpatient/institutional care were reduced, as well as parent- and adolescent-reported internalizing and externalizing symptoms. Furthermore, school attendance and adjustment were improved, and the adolescents reported experiencing less criticism while parents reported less emotional over-involvement. The results were maintained at follow-ups. CONCLUSIONS: The adolescents and the parents reported improvements for the main outcomes. This treatment appears promising in keeping the families in treatment and out of hospital, suggesting that an integrative approach may be beneficial and feasible for this group. TRIAL REGISTRATION: This study has been approved 19/12 2011, by the regional review board in Stockholm (Dnr 2011/1593-31/5).

Individuals' experiences with brief admission during the implementation of the brief admission skåne RCT, a qualitative study.

BACKGROUND: Brief admission (BA) is an adjunctive treatment option for individuals with self-harming behavior, having traits of borderline personality disorder (BPD). It is offered alongside outpatient psychotherapy for the purpose of strengthening autonomy, self-reflection and self-care and to increase the likelihood of being able to stay in therapy by avoiding lengthy inpatient hospitalizations. AIMS: To investigate participants' experiences with BA during the pilot phase of the Brief Admission Skåne Randomized Controlled Trial (BASRCT), in order to detect possible strengths and limitations of the intervention and gain knowledge to facilitate implementation of BA at other treatment centers. METHOD: Eight participants randomized to BA were interviewed to obtain their experience of BA, or alternatively their reasons for choosing not to use BA. Thematic analysis was conducted upon their transcribed interviews. RESULTS: Reported as most helpful by the participants was the structure/routines at the ward and the positive attitudes from the staff. However, some individuals reported problems with perceived negative attitudes from the staff administering BA and negative rumination about themselves. The reported reasons to request BA were: preventing urges to self-harm from escalating; ending isolation; preventing longer admissions and forced admission; feelings of emotional exhaustion, and the need for rest and support in re-creating a daily routine. Reasons for not requesting BA were fear of rejection, questioning the method; presumed room shortage; difficulties in deciding whether one's problems are serious enough; experiencing the situation to be too clinically acute. CONCLUSION: The results from this study indicated the importance of repeated staff education on all aspects of BA when it is being newly implemented, as well as the importance of working with attitudes of staff delivering BA. These were the key ingredients in making BA implementation successful. Our findings may be of value to other treatment centers implementing BA for the first time. TRIAL REGISTRATION: NCT02985047.

A standardized crisis management model for self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder: The Brief Admission Skåne randomized controlled trial protocol (BASRCT).

BACKGROUND: Brief Admission is a crisis and risk management strategy in which self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder self-admit to hospital at times of increasing risk when other efforts to stay safe are failing. Standardized in the current randomized controlled trial, the intensity of Brief Admission Skåne is implemented in durations of three days, with a maximum frequency of three times a month. Brief Admission is integrated into existing treatment plans in advance of crises to prevent reliance on general psychiatric admissions for risk management, as these may be lengthy, unstructured, and of uncertain therapeutic value. METHODS/DESIGN: The overall objective of the Brief Admission Skåne randomized controlled trial is to determine if Brief Admission can replace general psychiatric admission for self-harming and suicidal individuals with complex mental illness at times of escalating risk. Other objectives of the study are to evaluate whether Brief Admission increases daily functioning and enhances coping, reduces psychiatric symptoms including frequency and severity of self-harm and suicidal behaviours. A final objective is to determine if Brief Admission is an effective crisis management model for this population. Participants are randomized at an individual level to either Brief Admission Skåne plus Treatment as Usual or Treatment As Usual. Based on a priori power analyses, N = 124 participants will be recruited to the study. Data collection is in progress, and will continue until June 2018. All participant data are single-blinded and will be handled with intention-to-treat analysis. DISCUSSION: Based on the combined clinical experience of our international research group, the Brief Admission Skåne randomized controlled trial upon which the current protocol is based represents the first initiative to standardize, implement and evaluate Brief Admission amongst self-harming and suicidal individuals, including those with borderline traits. Objectively measuring protocol fidelity and developing English-language Brief Admission study protocols and training materials are implementation and dissemination targets developed in order to facilitate adherent international export of Brief Admission Skåne. TRIAL REGISTRATION: NCT02985047 . Registered November 25, 2016. Retrospectively registered.