Lack of Identity and Suicidality: The Mediating Role of Emotion Regulation Difficulties.

ABSTRACT: Identity disturbance has been connected to both psychological distress and suicidality, and associated with emotion dysregulation. However, despite empirical evidence of a relationship between lack of identity and poor psychiatric outcomes, the link between impaired identity and emotion dysregulation in suicide risk remains underexplored, particularly among individuals seeking outpatient mental health services. Using data from a large clinical sample (n = 246), the present study examined the association between lack of identity and suicidality and the role of emotion dysregulation within this process. Findings indicated that the mediation model was significant, with emotion regulation difficulties significantly mediating the association between lack of identity and future suicidal behavior. Furthermore, the indirect effect of lack of identity on anticipated suicidality remained significant beyond general distress and past suicide attempt. Our findings add to the literature examining the complex relationship among lack of identity, emotion regulation, and suicidality.

Sexual risk behavior among individuals seeking outpatient mental health services: Associations with childhood emotional neglect and identity dysfunction.

This study was developed to examine sexual risk behavior among patients seeking community-based mental health services, including associations with psychological distress, identity dysfunction, and childhood emotional neglect. A mediation model was examined regarding identity dysfunction mediating the link between emotional neglect and sexual risk behavior. A total of 245 outpatients completed questionnaires regarding perceived risky sexual behavior, psychological distress, identity dysfunction, and emotional neglect. Sexual risk behavior was found to be a prevalent issue among individuals seeking outpatient mental health services, with 13% reporting engagement in unsafe sexual practices at least some of the time. Mediation analysis revealed that childhood emotional neglect was indirectly linked with sexual risk behavior through the mediating effect of identity dysfunction. Thus, findings suggest a pathway to sexual risk behaviors through perceived childhood emotional neglect and identity dysfunction. Clinical attention to identity-related vulnerability among this population may be warranted in aiming to mitigate risk-taking associated with sexual practices.

Shame and guilt as mediators between dispositional optimism and symptom severity among mental health outpatients.

Dispositional optimism is robustly associated with psychological wellbeing, and individuals with lower optimism tend to experience more depressive and anxiety symptoms. While mechanisms in this relationship such as coping and social integration have been explored, limited research has examined whether the self-conscious emotions of shame and guilt account for the association between dispositional optimism and psychological distress. The present study examined shame and guilt as mediators in the relation between dispositional optimism and depressive and anxiety symptom severity among 137 patients (M age = 33.5, SD = 12.08 years) seeking community-based mental health care. Mediation analyses using bootstrap 99% confidence intervals indicated significant mediation by guilt--but not shame--in the model predicting depressive symptoms, and significant mediation by shame--but not guilt--in the model predicting anxiety symptoms. These findings suggest differential effects of dispositional optimism on depressive and anxiety symptoms according to the predominance of shame- or guilt-related affects. Interventions seeking to reduce distress through promoting optimism may be enhanced by considering patients' experiences of shame and guilt.

Childhood maltreatment and suicidality among women seeking mental health care: the mediating effect of borderline personality features, moderated by age.

Although childhood maltreatment is known to elevate women's risk for suicidal ideation and behavior, research concerning the mechanisms involved remains limited. While borderline personality disorder (BPD) has been implicated as mediating this association, such effects may differ depending on women's age. The present study examined borderline personality features as a dispositional mediator of the relationship between childhood maltreatment and suicidality, with the moderating effect of age, among help-seeking women. A sample of 151 women attending community mental health clinics completed measures of childhood maltreatment, BPD features, suicidality, and psychological distress. Regression analyses tested moderated mediation, controlling for psychological distress across each path. Results indicated a significant interaction between childhood maltreatment and age in predicting borderline personality features, and significant moderated mediation in predicting suicidality. Borderline personality features significantly mediated the association between maltreatment and suicidality among younger--but not among older--women, with the mediation effect becoming stronger as women were younger. The findings indicate borderline personality features as particularly salient among young women in accounting for the maltreatment-suicidality association. Thus, interventions addressing BPD may warrant consideration for young women with suicidal ideation and history of childhood adversity.

Acceptance and Commitment Therapy for Psychosis and Trauma: Investigating Links between Trauma Severity, Attachment and Outcome.

BACKGROUND: Although Acceptance and Commitment Therapy (ACT) may be effective for individuals with psychosis and a history of childhood trauma, little is known about predictors of treatment response among such patients. AIMS: The current study examined: (1) whether severity of trauma predicted treatment response, and (2) profiles of patients with regard to their responses to treatment. METHOD: Fifty participants with psychosis and childhood trauma history were recruited and randomized to take part in either eight sessions of group-based ACT, or to be on a waiting list for the ACT group (i.e. treatment as usual group). The entire sample was used for the first part of the analyses (aim 1), whereas subsequent subsample analyses used only the treatment group (n = 30 for aim 2). RESULTS: It was found that trauma severity did not moderate the effectiveness of ACT on symptom severity, participants' ability to regulate their emotional reactions, or treatment compliance with regard to help-seeking. In addition, among those receiving ACT, the results revealed three distinct and clinically relevant change profiles. Avoidant attachment style and number of sessions attended were predictive of belonging to the different clusters or profiles. Patients in the profile representing the least amount of clinical change attended an average of two sessions less than those in the other change profiles. CONCLUSION: ACT offered in a group format appears to be a promising treatment for those with psychosis and history of trauma regardless of trauma severity. Given the brevity of the intervention, patients should be encouraged to attend each session to obtain maximum benefit.

Childhood trauma and somatic symptoms among psychiatric outpatients: Investigating the role of shame and guilt.

Previous research suggests a link between experiences of childhood maltreatment and adult somatic symptom distress. Contributing mechanisms, however, are not yet well understood. It is possible that shame and guilt may function as mediators in the relationship between childhood trauma and adult somatic distress. The present study was developed to investigate the relationship between childhood maltreatment and adult somatic distress, including the potential mediating role of shame and guilt, among psychiatric outpatients. Using data from a sample of 99 Canadian psychiatric outpatients, mediation models with shame and guilt as parallel mediators were evaluated for relationships between childhood emotional abuse, sexual abuse, emotional neglect, and somatic symptoms. Controlling for current depressive symptoms, a significant indirect effect was found for the relationship between emotional abuse and shame, but not guilt, in contributing to somatic symptoms. A similar result was obtained regarding the mediating role of shame in the relationship between emotional neglect and somatic symptoms. Mediation was non-significant regarding childhood sexual abuse, which was directly related to somatic distress after controlling for depressive symptoms. The findings provide further evidence of the link between childhood trauma and somatic symptom distress, with shame as a mechanism for the effects of emotional abuse and neglect.

Acceptance and commitment therapy for psychosis and trauma: Improvement in psychiatric symptoms, emotion regulation, and treatment compliance following a brief group intervention.

OBJECTIVES: Acceptance and Commitment Therapy (ACT) has shown effectiveness for individuals with psychosis and individuals with a history of childhood trauma, but has not been investigated with people with psychosis who also have a history of childhood trauma. This study aims at determining the efficacy of a mindfulness-based ACT with this clientele in diminishing psychiatric symptoms, trauma-related symptoms, as well as in improving treatment adherence. DESIGN AND METHODS: Fifty participants meeting our inclusion criteria were recruited and randomized to take part in either 10 sessions of ACT group, or Treatment as Usual (TAU). RESULTS: Using RCT it was found that symptom severity, for both overall symptoms (BPRS) and anxiety (GAD), decreased over the course of the treatment, and participants' ability to regulate their emotional reactions (i.e., accept them) increased. The study also found that treatment engagement increased with regards to help-seeking for those in the ACT group, compared with the TAU controls. CONCLUSIONS: Acceptance and Commitment Therapy offered in a group appears a promising treatment for those with psychosis and history of trauma. PRACTITIONER POINTS: To understand the benefits of ACT with those who suffer from psychosis and a history of trauma. To further the understanding of the effectiveness of ACT.

A comparison of treatment adherence in individuals with a first episode of psychosis and inpatients with psychosis.

In predicting treatment compliance in individuals with severe mental illness, research has focused on variables such as substance abuse, personality, history of child abuse, and symptomatology, although these relationships have not been investigated in great detail in individuals at the onset of mental illness. To better understand these correlates of treatment compliance, two samples were examined: a sample of 117 individuals presenting with a first episode of psychosis and a more chronic forensic sample of 65 participants recruited from a psychiatric hospital. These samples were investigated for service engagement in terms of violence history, substance abuse, symptom severity, psychopathic traits and history of childhood abuse. Linear regressions performed for the first episode sample revealed that childhood physical abuse was the strongest predictor of poor service engagement, followed by problems with alcohol, a history of physical violence, any history of violence and higher psychopathic traits. Linear regression revealed for the forensic group that a lower level of service engagement was most strongly predicted by a history of childhood abuse and a higher score on the Brief Psychiatric Rating Scale (BPRS). Results are presented in light of the existing literature and clinical implications are discussed.

Factors impacting decisions to decline or adhere to antidepressant medication in perinatal women with mood and anxiety disorders.

PURPOSE: To identify specific quantitative and qualitative factors that govern the decision to adhere or decline antidepressant medication in antenatal women with moderate-to-severe mood and anxiety disorders. METHODS: Fifty women (30 adherers, 20 decliners) were recruited between 18 and 34 weeks gestation in a tertiary care clinic for perinatal mothers. They were prospectively monitored 4 weeks apart up to 1-month postpartum on the: Hamilton Anxiety Scale, Hamilton Depression Scale, Mood Disorders Insight Scale, Antidepressant Compliance Questionnaire, Penn State Worry Questionnaire, and NEO Personality Inventory. Qualitative interviews were conducted at baseline. Hierarchical linear modeling determined illness trajectories of the two groups. RESULTS: Significantly different course of illness was observed in adherers versus decliners. Adherers had healthier attitudes toward depression and compliance with medication (P < .005). Decliners had less illness insight (P < .001) and cited fear of fetal exposure, and thought medication was unwarranted. CONCLUSIONS: Pregnant women experienced significantly divergent illness trajectories depending on if they accepted antidepressant medication therapy for their illness. Risk perception, attitudes, and illness insight impacted decisions surrounding adherence and decline.

Early psychosis and aggression: predictors and prevalence of violent behaviour amongst individuals with early onset psychosis.

Studies in the area of psychosis and violence to date suggest that those who suffer from psychosis are at higher risk for perpetration of such aggressive behaviours. In fact, it has been suggested that variables such as substance use and personality may mediate this relationship. Other variables, such as childhood physical abuse, might also be implicated in the etiology. In the current study, a sample of one hundred and eighteen participants with a primary diagnosis of psychosis were interviewed and prevalence rates for aggressive experiences were as follows: history of trouble with the law (45%), history of emotional abuse (9.6%), physical abuse (38.8%), and sexual abuse (60.2%). With regard to perpetration, 69.6% reported verbal or physical aggression (69.6%), and further, 61% reported problems with substances. Logistic regression procedures were used with a number of the variables under study and relationships were evidenced between psychopathy scores, history of abuse, and regular drug use. History of child abuse was related to violence history, with those who were victims of child abuse being more likely to be violent in later life. In addition higher scores on the psychopathy measure were linked with violence history. This study was a first step towards identifying persons suffering from a mental illness who may be at risk for violence by identifying who, among first episode clients, may be more likely to perpetrate violent behaviours. Targeted interventions and strategies may be further refined so that individuals receiving mental health services may be better served.

Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial.

This study aimed at determining the effectiveness of group cognitive behavior therapy (CBT) for recent onset psychosis in comparison with a recognized intervention for individuals with severe mental illness-social skills training. One hundred twenty-nine participants took part in a single-blind randomized controlled trial with repeated measures (baseline, 3 months, and 9 months). Participants were randomized to 1 of 3 conditions: group CBT, group social skills training for symptom management, or a wait-list control group. Both interventions were delivered by mental health staff with minimal training. Both treatments resulted in improvements on positive and negative symptoms compared with the wait-list control group, with the CBT group having significant effects over time on overall symptoms, and post-treatment effects on self-esteem, and active coping skills compared with the wait-list control group and lower drop-out rates than the skills training group. Therapist fidelity was adequate for both treatment conditions. Group CBT for psychosis is a promising intervention for individuals with recent onset of psychosis and their mental health professionals.

Predictors and profiles of treatment non-adherence and engagement in services problems in early psychosis.

Treatment adherence in early psychosis individuals is considered problematic. Some studies have tried to understand reasons for medication non-adherence in this population, though few have also considered engagement in services. We conducted a cross-sectional study with 118 early psychosis individuals, assessing multiple constructs (symptoms, insight, personality traits, alliance, childhood trauma, substance abuse, social functioning and sociodemographics) suggested in the literature as potentially linked to medication adherence or engagement in services. Forward Wald logistic regression suggested that more positive symptoms, having witnessed violence as a child and high agreeableness as a personality trait predicted poor medication adherence. Forward linear regression revealed that physical abuse as a child, lack of knowledge regarding consumer rights, difficulties in building an alliance, low neuroticism and high agreeableness predicted poor service engagement. Profiles of non-adherers or low service engagement were strongly linked to childhood trauma, and high agreeableness, as well as more severe symptoms and poor alliance. Males with histories of legal problems were also more prevalent in both groups. No significant differences were found for insight or substance abuse. Overall, individuals with early psychosis who adhered less to treatment in general could have issues with trusting authority and place more importance on peer acceptance. Results are presented in light of the existing literature and clinical implications are discussed.

Psychopathy in women: a review of its clinical usefulness for assessing risk for aggression and criminality.

Despite a flurry of studies examining psychopathy in women, and the recent release of the second version of the Hare Psychopathy Checklist--Revised manual, there is still little consensus whether the lateral extension of the current conceptualization of psychopathy to women is appropriate. In particular, very little agreement exists concerning the clinical utility of the Hare psychopathy measures to assess women's risk of future offending and violence. This article presents a comprehensive review of studies of the association between psychopathy, antisocial behavior, and violence, in diverse samples of women, and looks at similarities and differences between these constructs in males and females. Findings from inmates and offenders, civil and forensic psychiatric patients, substance abusers, and community samples indicate a consistently lower base rate of psychopathy among women than among men. With some exceptions, correlates of psychopathy in women relevant to risk assessments for crime and violence tend to be modest and significant, generally mirroring what we see in men. Clinicians and policy makers charged with the care and management of women at risk for criminal offending and violence are likely to find the PCL-R and PCL:SV have clinical utility; however, cautious application is called for and ongoing research is required.

Of mice and men: will the intersection of social science and genetics create new approaches for intimate partner violence?

The past two decades have yielded a recognition that intimate partner violence is ubiquitous. Although violence within relationships is bidirectional, there is acknowledgment that violence directed against women is more persistent and dangerous. Strategies for treatment of men have been largely unsuccessful, and studies of women centered approaches to prevention are in their infancy. An emerging concept in the brain-behavior field is the recognition of genetics as a powerful influence on aggressive and violent behaviors. Mouse models of human health and disease have facilitated our understanding of the role of genetics in the manifestation of these traits. There is a need to push the boundaries of research on intimate partner violence by adopting biosocial approaches to understand its causes.