Brief internet-delivered skills training based on DBT for adults with borderline personality disorder - a feasibility study.

OBJECTIVE: Borderline personality disorder (BPD) is characterized by instability in emotions, relationships, and behaviors, such as self-injury and suicidal behavior. Dialectical Behavioral Therapy (DBT) is an established intervention for BPD, but there are long waiting times for treatment. This study aimed to explore if a brief internet-delivered DBT skills training program with minimal therapist support is acceptable, that it can be administered, useful, and does not do harm for patients with BPD. METHODS: Acceptability was measured through data on recruitment and attrition, utilization of the intervention, reported impulses to drop out, and through ratings on self-injury and suicidality. Participants were interviewed about their experiences of the intervention; analyzed with content analysis. RESULTS: Twenty patients on the waiting list for treatment at a DBT-clinic were invited and nine female patients (age 19-37 years) volunteered. The participants completed a large part of the intervention, which did not appear harmful since ratings of suicidal and self-harming behavior were similar before and after the intervention. In the interviews, participants stated that they had gained new knowledge and skills to manage situations, e.g. to stop and think before acting. Some even reported decreased levels of self-injury. The time spent on patient contact was short, and some patients reported difficulties to practice on their own and requested more support. CONCLUSIONS: The intervention seems to be acceptable. Future studies should investigate in what ways some BPD patients are more susceptible to internet-delivered skills training than others, and if this intervention could be delivered within a stepped-care model.

The Self-Compassion Scale-Short Form: Psychometric evaluation in one non-clinical and two clinical Swedish samples.

BACKGROUND: Self-compassion has been defined as the ability to be with one's feelings of suffering in a warm and caring way. Research has shown a negative association between self-compassion and mental illness, and that low self-compassion can make psychotherapeutic effects less likely. The ability to measure a patient's self-compassion in a fast and reliable way is therefore important in investigating effects of psychotherapies. The aim of the present study was to evaluate the psychometric properties of the Swedish version of the Self-Compassion Scale-Short Form (SCS-SF) in both non-clinical (NC) and clinical samples. METHODS: Cross-sectional data were gathered in a NC community sample (n = 1,089), an eating disorder (ED) sample (n = 253) and a borderline personality disorder (BPD) sample (n = 151). All participants were asked to complete a number of questionnaires, including the SCS-SF, and 121 participants in the NC sample repeated the assessment after 2 weeks for test-retest analysis. RESULTS: Confirmatory factor analyses supported the first-order model suggested in previous research. Good internal consistency (Cronbach's alpha = 0.78-0.87) and test-retest reliability (intra-class correlation = 0.84) were demonstrated for the entire scale. Results also showed good convergent validity, demonstrating moderate negative associations between self-compassion and mental illnesses, as expected, and acceptable divergent validity, demonstrating weak positive associations between self-compassion and quality of life and mindfulness. DISCUSSION: The correlations between the SCS-SF and the instruments used for validation were weaker in the clinical samples than the NC sample. This may be due to difficulties measuring these constructs or that the associations differ somewhat between different populations, which could warrant further research. The results added some support to the assumption that self-compassion may overlap with mindfulness yet still represents a distinct construct. CONCLUSIONS: Analyses of the SCS-SF provided evidence of adequate to good psychometric properties, supporting use of the scale's total sum score and a first-order factor structure. This is in accordance with previous evaluations of the SCS-SF, suggesting that it is a reliable and time-efficient instrument for measuring a general level of self-compassion. This may be important when evaluating psychotherapy and investigating self-compassion and its influence on psychiatric illness.

Psychometric properties of the Eating Disorder Symptom List (EDSL), a brief questionnaire for weekly assessment of eating disorder symptoms.

Frequent assessment of eating disorder (ED) symptoms (e.g., on a weekly basis) may guide treatment planning in clinical services, and be an invaluable tool for improving clinical research. The aim of the present study was to evaluate the psychometric properties of a brief eight-item scale designed to assess ED behaviors during the preceding week (Eating Disorder Symptom List: EDSL). Cross-sectional data were collected in a non-clinical community sample (n = 406) and cross-sectional and longitudinal data were gathered in a clinical ED sample before and after treatment with Enhanced Cognitive Behavior Therapy for eating disorders (n = 47) and weekly during treatment with Radically Open Dialectical Behavior Therapy (n = 13). The EDSL showed acceptable to good internal consistency (α = 0.72-0.82) and test-retest reliability (r = 0.88). Convergent and divergent validity was satisfactory. Also, the EDSL was sensitive to change and could detect changes between before and after treatment, as well as on a weekly basis. We conclude that the EDSL is a brief scale entailing little patient burden, and that initial analyses of the scale provide preliminary evidence of satisfactory psychometric properties. The scale can be used for repeated measures in ED treatment studies and clinics to assess change or absence of change during treatment.

The relationship between self-control and symptoms of anxiety and depression in patients with eating disorders: a cross-sectional study including exploratory longitudinal data.

BACKGROUND: Personality style can partly be described as the way an individual controls and regulates emotions and can be divided into over- and undercontrol. Studies have indicated that personality style may impact the onset, clinical presentation, and recovery from an eating disorder (ED). Furthermore, symptoms of anxiety and depression are common in patients with EDs. However, the association between self-control levels and anxiety/depression symptoms in patients with EDs remains unknown. The main aim of this study was to assess how levels of self-control relate to anxiety/depression symptoms in patients with EDs, with a secondary, exploratory aim to assess the stability of self-control during treatment. METHODS: Patients were recruited from the outpatient ED clinic at the Uppsala University Hospital, between October 2014 and December 2019. In total, 227 patients (age: 25.4, SD: 7.1) were included at the start of their treatment, with 14 participants also completing post-treatment measurements. Self-control was assessed with the Ego Undercontrol scale (EUC-13), anxiety/depression symptoms with the Hopkins Symptoms Checklist (HSCL-25), and ED diagnosis and symptoms with the Eating Disorder Examination Interview (EDE-I) and Questionnaire (EDE-Q), respectively. RESULTS: A quadratic regression (n = 227) showed that levels of self-control accounted for about four percent of the variance in degree of global anxiety/depressive symptoms. Anxiety/depression symptoms were better explained by ED symptoms (R2 = 0.24). Visualizations in boxplots revealed a tendency for extreme values of both over- and undercontrol to be associated with higher levels of depression, whereas symptoms of anxiety increased with increasing undercontrol. In the exploratory analyses (n = 14) levels of self-control remained more stable than symptoms of anxiety and depression, which decreased significantly during ED treatment. CONCLUSIONS: Our results indicated that anxiety/depression symptoms, in patients with EDs, were not strongly correlated with levels of self-control, but rather with ED symptoms. However, extreme values of both over- and undercontrol showed a tendency to be associated with higher levels of depression symptoms, whereas anxiety symptoms increased with increasing levels of undercontrol. Future studies could benefit from considering both over- and undercontrol as potentially dysfunctional.

Eating disorders (EDs) are mental disorders characterized by a persevering behavioral disturbance in eating and distress in thoughts or emotions, significantly impairing psychosocial function and/or physical health. Anxiety and depression are common in patients with EDs.Studies have indicated that personality style may impact the onset, clinical presentation, and recovery from an ED. Personality style can be studied in terms of self-control, ranging from over- to undercontrol. However, it remains unknown how self-control relates to anxiety/depression in patients with EDs and its stability during ED treatment. This is what we aimed to investigate in this study, collecting data before treatment in 227 adult patients from a Swedish outpatient ED clinic, with 14 also completing post-treatment measurements.Our results indicated that global anxiety/depression levels in patients with EDs were not strongly correlated with levels of self-control, but rather with ED symptoms. Nevertheless, anxiety seemed to increase with increasing levels of undercontrol and extreme values of both over- and undercontrol showed a tendency to be associated with higher levels of depression. In the exploratory analyses self-control levels remained more stable during treatment than global anxiety/depression levels, which decreased significantly.

Cluster analysis of personality traits in psychiatric patients with borderline personality disorder.

BACKGROUND: Though the heterogeneous expression of symptoms of borderline personality disorder (BPD) is well-known, it is far from fully understood. Hybrid models combining dimensional and categorical ways of diagnosing BPD have been suggested to better handle this heterogeneity, but more research is needed. The aim of this study was to identify potential clusters in BPD, and evaluate if these clusters differed in diagnostic composition, severity, psychiatric symptoms, emotion regulation and control, or sociodemographic features. METHODS: Clusters were based on personality traits measured with the Swedish universities Scales of Personality (SSP) in 141 psychiatric patients diagnosed with BPD. Hierarchical cluster analysis was performed using Ward's method. We used one-way analysis of variance to explore the different clusters' properties. Effect sizes were calculated using partial eta squared. RESULTS: We found three distinct clusters: the lower psychopathology cluster (N = 67), the externalizing cluster (N = 28), and the internalizing cluster (N = 46). The clusters differed regarding trait composition, severity, and emotion regulation and control. CONCLUSIONS: Our findings support hybrid models for diagnosing BPD by showing that clusters differed in terms of both severity (lower and higher psychopathology) and personality traits/style (internalizing and externalizing). Assessment of personality traits may be a feasible way to differentiate between clusters. In the future, this knowledge might be used to personalize treatment.

The Social Safeness and Pleasure Scale (SSPS): a psychometric evaluation of the Swedish version in a non-clinical sample and two clinical samples with eating disorders or borderline personality disorder.

BACKGROUND: Social safeness and pleasure refer to the extent to which people experience their world as safe, warm, and soothing. Difficulties in achieving social safeness have been identified as a transdiagnostic vulnerability factor for developing and maintaining psychopathology and for feeling less contentment and self-compassion. The study aim was to evaluate the psychometric properties of the Swedish version of the Social Safeness and Pleasure Scale (SSPS). METHODS: The SSPS was evaluated in a non-clinical sample of 407 participants. The internal consistency and test-retest reliability of the SSPS were explored and a confirmatory factor analysis was performed. Convergent validity was studied based on the assumption of negative correlations with the personality traits detachment and mistrust, derived from the Swedish Universities Scale of Personality. Divergent validity was studied based on the assumption of no or small correlations with impulsiveness and adventure-seeking-personality traits not assumed to be related to social safeness. Validity was also investigated by comparing the SSPS results in the non-clinical sample with those in two clinical groups of patients diagnosed with either borderline personality disorder (BPD; n = 58) or eating disorders (n = 103), recruited from two psychiatric outpatient clinics. RESULTS: Confirmatory factor analysis confirmed a one-factor structure. Cronbach's alpha was 0.95 and test-retest reliability was 0.92. Validity was supported by moderate to strong negative correlations between the SSPS and the detachment and mistrust scales and no or small correlations with the impulsiveness and adventure-seeking scales in a personality questionnaire. Finally, we found significantly lower mean values on the SSPS in the clinical groups compared with the non-clinical group, with the lowest mean in the BPD sample. CONCLUSIONS: The results showed good to excellent psychometric properties for the Swedish version of the SSPS, supporting its use in both clinical practice and research. Future research could use the SSPS when evaluating interventions aimed at improving the ability to develop social safeness, such as compassion-focused therapy or radically open dialectical behavior therapy, interventions that may be particularly important in BPD patients.

The self-efficacy in distress tolerance scale (SE-DT): a psychometric evaluation.

BACKGROUND: Skills training is believed to be essential in dialectical behavior therapy (DBT) and is also offered as a standalone intervention. There is a need to better understand each skills module's separate contribution to treatment outcomes. Several assessment instruments are available, but none of them provides specific information about patients' perceived ability to use skills promoting distress tolerance. The aim of the present study was to develop and evaluate the psychometric properties of a Swedish adaptation of the General Self-Efficacy scale (GSE) for skills use in distress tolerance - the Self-Efficacy in Distress Tolerance scale (SE-DT). METHODS: Cross-sectional and longitudinal data were gathered in a non-clinical (NC) community sample (n = 407) and a clinical psychiatric (CP) sample (n = 46). Participants in the NC sample were asked to complete a set of 19 self-report instruments, including the SE-DT, and 45 participants repeated the assessment after 2 weeks. The patients in the CP sample filled out a subset of eight instruments; twenty patients repeated the assessment after completing a treatment intervention including mindfulness skills and distress tolerance skills or emotion regulation skills. RESULTS: The analyses showed that the SE-DT is unidimensional with high internal consistency (Cronbach's alpha = .92) and good test-retest reliability (intraclass correlation = .74). The SE-DT also showed good convergent and divergent validity, demonstrating positive correlations with general self-efficacy and self-compassion, and negative correlations with difficulties in emotion regulation, psychiatric symptoms, and borderline symptoms. The SE-DT showed sensitivity to change, when pre- and post-treatment assessments were compared (Cohen's d = 0.82). DISCUSSION: This is preliminary evidence that the SE-DT has adequate to good psychometric properties, supporting the use of a total sum score. The results indicate that the SE-DT can adequately measure the construct of self-efficacy with regard to dealing with distress and emotional crises. The instrument enables continued investigation of standalone skills training and the specific contribution of distress tolerance skills to treatment outcomes in DBT. Further studies are needed to investigate whether these results are valid in other populations. In addition, the field would benefit from a common definition of distress tolerance.

Overcontrolled, undercontrolled, and resilient personality styles among patients with eating disorders.

BACKGROUND: Personality has been suggested to be an important factor in understanding onset, maintenance, and recovery from eating disorders (ED). The objective of the current study was to evaluate personality style in different ED diagnostic groups as classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5). METHODS: The overcontrolled, undercontrolled, and resilient personality styles were compared in four groups of patients with EDs: anorexia nervosa restricting (ANr) (n = 34), anorexia nervosa binge eating/purging (ANbp) (n = 31), atypical anorexia nervosa (AAN) (n = 29), and bulimia nervosa (BN) (n = 76). These groups were compared with a group of patients with borderline personality disorder (BPD) (n = 108), and a non-clinical group (NC) (n = 444). Patient data were collected at two outpatient clinics in Uppsala, Sweden. NC control data were collected through convenience sampling. Participants filled out questionnaires assessing personality style. RESULTS: The main findings were more pronounced overcontrol reported by the ANr and AAN groups compared with the BN, BPD, and NC groups, and no significant difference in resilience between the ED and the NC groups. Considerable variability of over- and undercontrol was also found within each group. CONCLUSIONS: The results replicate previous findings when EDs are classified according to current diagnostic criteria (DSM-5). Taking personality styles into account may improve our understanding of certain characteristics in EDs, such as social deficits and rigidity that are attributed to poor treatment outcome.

Sharing and connecting with others - patient experiences of radically open dialectical behavior therapy for anorexia nervosa and overcontrol: a qualitative study.

BACKGROUND: Recovery rates after psychological treatments for anorexia nervosa are low to moderate, and in adults, no treatment outperforms any other. The aim of this study was to evaluate patient experiences of Radically open dialectical behavior therapy (RO DBT), a treatment developed for disorders related to maladaptive overcontrol. METHODS: Eleven female patients with anorexia nervosa were interviewed after either treatment completion (eight patients) or drop-out (three patients) from RO DBT. Interviews were transcribed and analyzed with inductive thematic analysis. RESULTS: The analysis yielded five main themes: 1) a comprehensive treatment, 2) the benefits of sharing and connecting with others, 3) growing trust, 4) moving toward valued goals - but some remain, and 5) doing well in treatment. CONCLUSION: Patients appreciated what they described as a comprehensive treatment and holistic view of their problems, which helped them reduce both maladaptive overcontrol and eating disorder symptoms. Gradually sharing personal experiences both in- and outside therapy was described as essential and led to enhanced social connectedness. TRIAL REGISTRATION: The intervention study (Isaksson M, et al. J Behav Ther Exp Psychiatry. 71, 2021) that preceded this interview study was performed by the first, second, third, and fifth author, preregistered in the ISRCTN registry (no: ISRCTN47156042 ).

Radically open dialectical behavior therapy for anorexia nervosa: A multiple baseline single-case experimental design study across 13 cases.

BACKGROUND AND OBJECTIVES: No treatment for adult anorexia nervosa (AN) has shown sufficient effectiveness or superiority to other treatments. Overcontrol has been suggested as a viable mechanism to target in the treatment of patients with AN. Radically open dialectical behavior therapy (RO DBT) is developed for disorders related to maladaptive overcontrol. Our objective was to evaluate the outcome of RO DBT for AN in a clinical outpatient setting. METHODS: Thirteen adult female patients with mild to moderate AN provided written consent and entered a multiple baseline single-case experimental design study. Median age at eating disorder (ED) onset was 15 years and the median duration of the ED was 10 years. Individual changes were assessed weekly during a baseline phase (A) of four to six weeks, and during the subsequent 40-week RO DBT phase (B). Additional assessments were conducted before and after treatment, and at a six-month follow-up. Primary outcome was ED psychopathology. Secondary outcomes were psychosocial impairment, quality of life, social connectedness, and adaptive control strategies. RESULTS: Eight patients (62%) completed treatment. All completers were in full remission after treatment, with BMI ≥18.5 kg/m2 and ED psychopathology within one standard deviation of the community mean. Improvements occurred after introducing RO DBT, not during baseline. LIMITATIONS: Participants were female with mild to moderate AN, limiting generalizability to severe AN or males. CONCLUSIONS: The study provides preliminary support for using RO DBT in adult outpatients with AN and overcontrol. Further studies should replicate these findings.

Perception of Verbal and Nonverbal Emotional Signals in Women With Borderline Personality Disorder: Evidence of a Negative Bias and an Increased Reliance on Nonverbal Cues.

Studies conducted in patients diagnosed with borderline personality disorder (BPD) have documented a variety of anomalies concerning patients' abilities to interpret emotional signals. Attempting to clarify the bases of these anomalies, the current literature draws attention to a possible role of dysfunctional expectations, such as the expectation of social rejection. Dysfunctional expectations, however, may not only bias social interpretations, but may also focus attention on social cues most important in conveying emotional messages, such as nonverbal signals. To explore these assumptions, 30 female BPD patients were tasked to judge the valence of emotional states conveyed by combinations of verbal and nonverbal emotional cues. Compared to controls, BPD patients exhibited a negative bias in their interpretations and relied more on available nonverbal cues. Shifts in the relative importance of nonverbal cues appeared to be rooted mainly in a reduced reliance on positive verbal cues presumably deemed less credible by BPD patients.