Interpersonal Support Domains Associated With Symptoms of Posttraumatic Stress Among Older Black and White Adults.

Objective: Older adults experience numerous changes in their social networks and social environment that may worsen preexisting posttraumatic stress disorder (PTSD) symptoms. This study tested whether tangible support, appraisal support, belonging support, and self-esteem were associated with trauma symptom burden among community-dwelling older Black and White adults at baseline and over 12 months of follow-up.Methods: This study used data collected from a randomized controlled trial for depression prevention in adults 50 years of age or older who had subsyndromal depression (2006-2011). Two hundred forty-four participants (including 90 older Black adults) were randomly assigned to a problem-solving therapy arm or an active control arm. The Interpersonal Support Evaluation List (ISEL) was administered at baseline and 12 months later. Linear regression analysis was used to examine associations of each of the ISEL dimensions with DSM-IV-defined PTSD symptoms at baseline and over time, with control for well-established correlates of PTSD including depression, anxiety, and sleep quality.Results: Participants were a mean (SD) of 65.6 (11.0) years of age, and 71% percent were female. Belongingness support was the only dimension of interpersonal support significantly associated with PTSD symptoms at baseline (ß = -0.192, t = -3.582, P < .001) and 12 months later (ß = -0.183, t = -2.735, P < .01). Regression models accounted for a large proportion of variance in PTSD symptoms. The association between belongingness support and PTSD symptoms did not vary by participant race.Conclusions: A strong perception of belongingness to family and/or friends was associated with fewer PTSD symptoms at baseline and over 12 months. This observation generates the hypothesis that behavioral interventions which directly target and modify interpersonal support may benefit both older Black and older White adults who have experienced trauma.Trial Registration: ClinicalTrials.gov identifier: NCT00326677.

An Internet-Based Self-Management Intervention to Reduce Fatigue Among People With Traumatic Brain Injury: A Pilot Randomized Controlled Trial.

IMPORTANCE: Fatigue is a chronic and distressing sequela of traumatic brain injury (TBI). Little evidence exists for the efficacy of interventions that address post-TBI fatigue. OBJECTIVE: To evaluate the preliminary efficacy of a self-management intervention (Maximizing Energy; MAX) for reducing the impact (primary outcome) and severity of fatigue on daily life, improving fatigue experience, and increasing participation compared with a health education (HE) intervention. DESIGN: Pilot randomized controlled trial (RCT). SETTING: Community. PARTICIPANTS: Forty-one participants randomly assigned to the MAX (n = 20) or HE (n = 21) intervention. INTERVENTIONS: The MAX intervention included problem-solving therapy with energy conservation education to teach participants fatigue management. The HE intervention included diet, exercise, and energy conservation education. Both interventions (30 min/day, 2 days/wk for 8 wk) were delivered online by occupational therapists. OUTCOME AND MEASURES: The primary outcome was the modified Fatigue Impact Scale (mFIS). Outcome measures were collected at baseline, postintervention, and 4- and 8-wk postintervention. RESULTS: At 8 wk postintervention, participants in the MAX group reported significantly lower levels of fatigue impact (mFIS) than those in the HE group, F(1, 107) = 29.54, p = .01; Cohen's d = 0.87; 95% confidence interval [0.18, 1.55]. CONCLUSIONS AND RELEVANCE: These findings provide preliminary evidence that the MAX intervention may decrease the impact of fatigue on daily life among people with post-TBI fatigue. What This Article Adds: An internet-based, self-management intervention combining occupational therapy- delivered energy conservation education with cognitive-behavioral therapy seems to reduce fatigue impact and severity among people with post-TBI fatigue. Future appropriately powered RCTs could positively contribute to the evidence available to occupational therapy practitioners for this chronic, debilitating, and often overlooked symptom.

Problem-Solving Therapy for Older Adults at Risk for Depression: A Qualitative Analysis of the Depression in Later Life Trial.

OBJECTIVE: As a sequel to the Depression in Later Life trial of lay counselor-delivered problem-solving therapy for depression prevention among older adults in Goa, India, this qualitative study aimed to explore participant experiences to illuminate the reasons for the trial's positive findings and implications for further efforts at depression prevention in low-resource settings. METHODS: In-depth interviews were conducted with 19 participants (21% of those randomly assigned to the original intervention). Two independent raters coded the data and organized narratives according to broad themes. RESULTS: Most participants valued their relationship with the lay counselor, learned self-care strategies to cope with illnesses, and increased engagement in pleasurable social and physical activities. Some participants reported needing assistance with managing financial strain and family conflicts. CONCLUSIONS: The lay-counselor-delivered intervention was well received. The relationship with the counselor and behavioral activation toward better self-care and more-pleasurable activities may have been keys to the intervention's success.

Adaptation of problem-solving therapy for primary care to prevent late-life depression in Goa, India: the 'DIL' intervention.

BACKGROUND: Depression in late life is a major, yet unrecognized public health problem in low- and middle-income countries (LMICs). The dearth of specialist resources, together with the limited ability of current depression treatments to avert years lived with disability, underscores the need for preventive interventions that can be delivered by lay health workers in primary care settings. We describe the development of an intervention for the indicated prevention of depression in older adults at risk due to subsyndromal symptoms, attending rural and urban public primary care clinics in Goa, India. OBJECTIVES: (1) to describe a mixed-methods approach (qualitative and quantitative)to the development of 'DIL,' an intervention for preventing the onset of major depression in older adults living with subsyndromal symptoms in Goa, India; (2) to describe resulting components of the 'DIL' intervention; and (3) to present data on the feasibility, acceptability, and benefit of DIL to participants. METHODS: We followed a mixed-methods design, including in-depth interviews, focus group discussions, a theory of change workshop to develop a logic model, and an open-case series. RESULTS: The mixed-method approach led to the development and adaptation of the DIL (Depression in Later Life) intervention for the indicated prevention of depression in older adults. The intervention was delivered by lay health counselors (LHCs). 'DIL' is a hybrid model of simple behavioral strategies grounded in Problem-solving Therapy for Primary Care, improved self-management of common, co-occurring medical disorders such as diabetes mellitus, and pragmatic assistance in navigating to needed social services. The use of 'DIL' in an open-case series with 19 participants led to a moderate reduction in symptoms of depression and anxiety on the General Health Questionnaire. A pictorial flipchart was developed to assist in delivering the intervention to participants with low levels of literacy. High rates of participant retention and satisfaction were achieved. CONCLUSION: The DIL intervention was adapted to the local context for delivery by lay health counselors and was found to be acceptable and feasible among the elderly participants in the study.

Problem-solving therapy reduces subjective burden levels in caregivers of family members with mild cognitive impairment or early-stage dementia: Secondary analysis of a randomized clinical trial.

OBJECTIVES: Interventions addressing burden have limited impact among long-term family caregivers. We examined whether problem-solving therapy (PST) would reduce burden levels of caregivers of individuals diagnosed with mild cognitive impairment (MCI) or early-stage dementia (AD). METHODS: Caregivers (N = 73) randomly received PST or nutritional training (NT). Burden measures were assessed over 1-year post-intervention. RESULTS: Relative to NT, caregivers receiving PST endorsed improved perceived burden levels over time, regardless of the type of caregiver. Distress over the care recipient's dementia-related behaviors remained low over time among MCI caregivers receiving PST, while these burden levels among MCI caregivers receiving NT rose over time. AD caregivers receiving PST endorsed reductions in these burden levels over time, while AD caregivers in the NT group endorsed higher burden levels over time. CONCLUSION: PST, taught early in the caregiving trajectory, improves subjective burden levels among caregivers of family members with relatively mild cognitive deficits.

Effect of a Lay Counselor Intervention on Prevention of Major Depression in Older Adults Living in Low- and Middle-Income Countries: A Randomized Clinical Trial.

Importance: Preventing depression in older adults living in low- and middle-income countries is important because of the scarcity of treatment resources and the risk of disability, suicide, and dementia. Objective: To assess whether an intervention for depression prevention provided by lay counselors is effective in older adults from low- and middle-income countries. Design, Setting, and Participants: This parallel-group randomized clinical trial with masked outcome assessment was performed in 181 older adults (≥60 years) with subsyndromal depressive symptoms at rural and urban primary care clinics in Goa, India. The first participant entered the trial on March 31, 2015, and the last exited on June 2, 2017. Data analysis used the intention-to-treat approach. Interventions: Lay counselors provided problem-solving therapy, brief behavioral treatment for insomnia, education in self-care of common medical disorders such as diabetes, and assistance in accessing medical and social programs. Main Outcomes and Measures: The main outcome was incidence of major depressive episodes. The study also assessed symptom change during 12 months (12-item General Health Questionnaire [GHQ-12]; score range of 0 to 12, with higher scores indicating greater symptoms of depression and anxiety), functional status (World Health Organization Disability Assessment Schedule 2.0; score range of 12 to 60, with higher scores indicating greater disability), cognition (Hindi Mini-Mental State Examination; score range of 0 to 30, with higher scores indicating better cognitive functioning), blood pressure, and body mass index to provide further clinical context. Results: The study enrolled 181 participants (mean [SD] age, 69.6 [7.2] years; 114 [63.0%] female): 91 to the intervention arm (depression in later life [DIL] intervention) and 90 to care as usual (CAU). Incident episodes of major depression were lower in the DIL intervention than in the CAU group (4.40% vs 14.44%; log-rank P = .04; number needed to treat, 9.95; 95% CI, 5.12-182.43). The 12-month Kaplan-Meier estimates of percentage of depression-free participants were 95.1% (95% CI, 90.5%-99.9%) in the DIL group vs 87.4% (95% CI, 80.4%-95.1%) in the CAU group. The incidence of depressive symptoms (GHQ-12) was also less (12-month mean difference, -1.18; 95% CI, -2.03 to -0.31; group × time interaction P < .001). There were no changes in measures of disability or cognition. The DIL intervention was associated with a significantly greater lowering of systolic blood pressure (12-month mean difference, -6.98; 95% CI, -11.96 to -2.01; group × time interaction P < .001) and change in body mass index (12-month mean difference, 0.23; 95% CI, -0.97 to 1.43; P = .04). Conclusions and Relevance: The DIL intervention is effective for preventing episodes of major depression in older persons with subsyndromal symptoms. If replicated, the DIL intervention may be effective in older adults living in low- and middle-income countries. Trial Registration: ClinicalTrials.gov Identifier: NCT02145429.

Protocol and Fidelity Monitoring Plan for Four Supports. A Multicenter Trial of an Intervention to Support Surrogate Decision Makers in Intensive Care Units.

Individuals acting as surrogate decision makers for critically ill patients frequently struggle in this role and experience high levels of long-term psychological distress. Prior interventions designed to improve the sharing of information by the clinical team with surrogate decision makers have demonstrated little effect on surrogates' outcomes or clinical decisions. In this report, we describe the study protocol and corresponding intervention fidelity monitoring plan for a multicenter randomized clinical trial testing the impact of a multifaceted surrogate support intervention (Four Supports) on surrogates' psychological distress, the quality of decisions about goals of care, and healthcare use. We will randomize the surrogates of 300 incapacitated critically ill patients at high risk of death and/or severe long-term functional impairment to receive the Four Supports intervention or an education control. The Four Supports intervention adds to the intensive care unit (ICU) team a trained interventionist (family support specialist) who delivers four types of protocolized support-emotional support; communication support; decisional support; and, if indicated, anticipatory grief support-to surrogates through daily interactions during the ICU stay. The primary outcome is surrogates' symptoms of anxiety and depression at 6-month follow-up, measured with the Hospital Anxiety and Depression Scale. Prespecified secondary outcome measures are the Patient Perception of Patient Centeredness Scale (modified for use with surrogates) and Impact of Event Scale scores at 3- and 6-month follow-up, respectively, together with ICU and hospital lengths of stay and total hospital cost among decedents. The fidelity monitoring plan entails establishing and measuring adherence to the intervention using multiple measurement methods, including daily checklists and coding of audiorecorded encounters. This approach to intervention fidelity may benefit others designing and testing behavioral interventions in the ICU setting. Clinical trial registered with www.clinicaltrials.gov (NCT01982877).

Effect of Problem-Solving Therapy Versus Supportive Management in Older Adults with Low Back Pain and Depression While on Antidepressant Pharmacotherapy.

OBJECTIVE: Testing stepped-care approaches that address both depression and low back pain are needed to optimize outcomes in older adults. METHODS: This university-based late-life depression research center assessed 227 adults aged ≥ 60 years with chronic low back pain and depression. In Phase 1 participants received 6 weeks of low-dose venlafaxine (≤150 mg/day). Nonresponders were randomized to 10 weeks of high-dose venlafaxine (up to 300 mg/day) plus problem-solving therapy (PST) or high-dose venlafaxine with supportive management. Definition of response was 2 weeks of Patient Health Questionnaire-9 ≤ 5 and ≥30% pain reduction on a numeric rating scale. Function was measured with the Short Physical Performance Battery (SPPB) and Roland Morris Disability Questionnaire (RMDQ). RESULTS: Of those who completed Phase 1 (N = 209), 78.5% (N = 164) were nonresponders and 139 proceeded to Phase 2, with 68 randomized to venlafaxine/PST and 71 randomized to venlafaxine/supportive management. Of those in venlafaxine/PST, 41.2% (28/68) responded, and of those in venlafaxine/supportive management, 39.4% (28/71) responded. Cumulative proportion responding over time did not differ across the two arms (hazard ratio: 1.07; 95% confidence interval: 0.63-1.80). We observed clinically significant improvements in physical performance (SPPB) and disability (RMDQ) across both Phase 1 and 2, independent of intervention. Over 12 months of follow-up there was no difference between groups for stability of depression, pain, or disability. CONCLUSION: The combination of antidepressant pharmacotherapy and PST was not superior to antidepressant pharmacotherapy and supportive management. Clinically, the rates of response and stability of response over 1 year observed in both groups suggest that these approaches may have clinical utility in these chronically suffering patients.

Aging and well-being in Goa, India: a qualitative study.

OBJECTIVES: The population of India is aging rapidly. This demographic shift brings with it a host of challenges to the health and well-being of older adults, including the increased prevalence of non-communicable diseases, among them depressive disorders. In this paper, we report on qualitative research intended to inform the development of a locally acceptable and appropriate intervention to improve the well-being of older adults in Goa, India and, specifically, to prevent late-life depression. METHOD: Semi-structured interviews with 20 individuals, aged 60 years and older, attending two primary care clinics in Goa, India. Transcripts were reviewed to identify emerging themes, a coding scheme was developed and thematic analyses were conducted. RESULTS: Analyses of the interview transcripts revealed the following key themes: (1) notions of old age tended to be negative and there were widespread fears of becoming widowed or incapacitated; (2) the most frequently reported health conditions were joint pain, diabetes and heart disease; (3) emotional distress was described using the terms 'tension', 'stress', 'worry' and 'thinking'; (4) family issues often involved financial matters, difficult relationships with daughters-in-law and conflicted feelings about living with the family or independently; (5) other than a pension scheme, participants did not know of community resources available to older adults. CONCLUSIONS: Our findings are in general agreement with those of previous research, and with our experiences of working with older adults in Pittsburgh and the Netherlands. This research will inform the development of an intervention to prevent depression in older adults in Goa.

Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study.

OBJECTIVE: Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research. METHODS: In an intervention development study, the authors administered problem-solving therapy (PST) dyadically to participants with mild cognitive impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. The dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) and the potential feasibility of the program are described. RESULTS: The authors found that the wife of the individual with MCI could be trained as a PST coach to help her husband learn and use problem-solving skills. A decrease in depressive symptom severity was observed for the individual with MCI, which was sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study. CONCLUSION: Dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients' support persons. Recommendations are offered for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.

Challenges and Solutions for Depression Prevention Research: Methodology for a Depression Prevention Trial for Older Adults with Knee Arthritis and Emotional Distress.

OBJECTIVE: To describe the methodology, challenges, and baseline characteristics of a prevention development trial entitled "Reducing Pain, Preventing Depression." METHODS: A sequential multiple assignment randomized trial (SMART) compared sequences of cognitive behavioral therapy (CBT) and physical therapy for knee pain and prevention of depression and anxiety. Participants were randomized to CBT, physical therapy, or enhanced usual care and followed for 12 months for new-episode depression or anxiety. Participants were age ≥ 60 with knee osteoarthritis and subsyndromal depression, defined as 9-item Patient Health Questionnaire (PHQ-9) score ≥1 (which included the endorsement of one of the cardinal symptoms of depression [low mood or anhedonia]) and no diagnosis of major depressive disorder per the Structured Clinical Interview for DSM-IV. Depression and anxiety severity and characterization of new episodes were assessed with the PHQ-9, Generalized Anxiety Disorder-7, and the PRIME-MD. Knee pain was characterized with the Western Ontario McMaster Arthritis Index. Response was defined as at least "Very Much Better" on a Patient Global Impression of Change. RESULTS: At baseline there were 99 patients with an average age of 71; 61.62% were women and 81.8% white. The average PHQ-9 was 5.6 and average Generalized Anxiety Disorder-7, was 3.2. Most were satisfied with the interventions and study procedures. The challenges and solutions described here will also be used in a confirmatory clinical trial of efficacy. CONCLUSION: A SMART design for depression and anxiety prevention, using both CBT and physical therapy, appears to be feasible and acceptable to participants. The methodologic innovations of this project may advance the field of late-life depression and anxiety prevention.

Feasibility of a Cognitive Behavioral Intervention to Manage Fatigue in Individuals With Traumatic Brain Injury: A Pilot Study.

OBJECTIVE: To evaluate the feasibility of conducting a randomized clinical trial of an Internet-based manualized intervention to teach individuals with traumatic brain injury to manage their fatigue. SETTING: Community dwelling. PARTICIPANTS: Forty-one participants randomized to Maximizing Energy (MAX) intervention group (n = 20) and Health Education group (n = 21). INTERVENTION: The experimental group (MAX intervention) received an 8-week program that combined education and Problem-Solving Therapy to teach individuals to manage fatigue-related problems. The attention control group received health education. MEASURES: Primary outcome measures pertained to the feasibility of conducting the trial. Secondary outcomes were fatigue impact and fatigue severity assessed at baseline and postintervention. RESULTS: Of the 65 participants referred, 41 were enrolled (63% recruitment rate), of which 3 withdrew (92% retention rate). Participants in the experimental and control groups completed their homework 75% and 85% of the time, respectively, and were equally engaged in the sessions. Participants in the experimental group were able to learn and implement the MAX intervention steps. Effect sizes for all measures ranged from small (-0.17) to medium (-0.58) in favor of the intervention group. CONCLUSION: Findings from the study suggest that the MAX intervention is feasible to administer to individuals with post-traumatic brain injury fatigue.

Prolonged physiological reactivity and loss: Association of pupillary reactivity with negative thinking and feelings.

Prolonged psychophysiological reactions to negative information have long been associated with negative thinking and feeling. This association is operationalized in the RDoC negative affect construct of loss, which is nominally indexed by prolonged physiological reactivity, cognitive loss-related constructs such as rumination and guilt, and more feeling-related constructs such as sadness, crying, and anhedonia. These associations have not been tested explicitly. If thinking and feeling aspects of loss reflect different physiological mechanisms, as might be suggested by their putative neurobiology, different intervention pathways might be suggested. Here we examined the extent to which self-reported negative thinking and feeling constructs were associated with prolonged pupillary reactivity following negative words and a subsequent cognitive distractor in a diverse heterogeneously diagnosed sample of N=84 participants. We also considered indices of abuse and variables associated with borderline personality disorder as possible moderators. Consistently, feeling-related negative affect constructs were related to prolonged pupillary reactivity during the distractor after a negative stimulus whereas thinking-related constructs were not. These data suggest that people who have sustained physiological reactions to emotional stimuli may be more strongly characterized by non-linguistic negative feelings than explicit cognitions related to loss. Sustained physiological reactions could reflect efforts to regulate feeling states. In contrast to cognitive and affective variables, abuse was associated with decreased physiological reactivity, consistent with decreased neural engagement. Interventions that target mechanisms underlying feelings and their regulation may be more mechanistically specific to sustained reactivity than those which directly address cognitions.

Perspectives of postmenopausal breast cancer survivors on adjuvant endocrine therapy-related symptoms.

PURPOSE/OBJECTIVES: To conduct an investigation of women's experiences related to adjuvant endocrine therapy (AET) and managing AET-related symptoms. RESEARCH APPROACH: Qualitative, focus group design. SETTING: Main campus of the University of Pittsburgh in Pennsylvania. PARTICIPANTS: 14 breast cancer survivors, aged 50 years or older, with AET-related symptoms. METHODOLOGIC APPROACH: Semistructured discussion guides were used to elicit recollections of conversations with healthcare providers about starting AET, symptom experiences, symptom management, and suggestions for improving management. Audiotaped discussions were transcribed and analyzed to identify themes. FINDINGS: Women reported that, initially, AET was not viewed as a choice, but rather as the necessary next step to save their lives. After starting AET, women experienced difficulties making sense of, communicating about, and managing unanticipated AET-related symptoms. Women who experienced persistently bothersome symptoms began weighing the pros and cons of AET to decide whether to continue treatment. CONCLUSIONS: Focus group findings suggest multiple opportunities to better prepare patients for AET and to improve assessment and management of AET-related symptoms. INTERPRETATION: By exploring AET-related symptom experiences, nurses may be able to promote AET adherence in breast cancer survivors.

Early intervention to preempt major depression among older black and white adults.

OBJECTIVE: The study objective was to assess the efficacy of problem-solving therapy for primary care (PST-PC) for preventing episodes of major depression and mitigating depressive symptoms of older black and white adults. The comparison group received dietary coaching. METHODS: A total of 247 participants (90 blacks, 154 whites, and three Asians) with subsyndromal depressive symptoms were recruited into a randomized depression prevention trial that compared effects of individually delivered PST-PC and dietary coaching on time to major depressive episode and level of depressive symptoms (Beck Depression Inventory) over two years. Cumulative intervention time averaged 5.5-6.0 hours in each study arm. RESULTS: The two groups did not differ significantly in time to major depressive episodes, and incidence of such episodes was low (blacks, N=8, 9%; whites, N=13, 8%), compared with published rates of 20%-25% over one year among persons with subsyndromal symptoms and receiving care as usual. Participants also showed a mean decrease of 4 points in depressive symptoms, sustained over two years. Despite greater burden of depression risk factors among blacks, no significant differences from whites were found in the primary outcome. CONCLUSIONS: Both PST-PC and dietary coaching are potentially effective in protecting older black and white adults with subsyndromal depressive symptoms from developing episodes of major depression over two years. Absent a control for concurrent usual care, this conclusion is preliminary. If confirmed, both interventions hold promise as scalable, safe, nonstigmatizing interventions for delaying or preventing episodes of major depression in the nation's increasingly diverse older population.

Adult Attachment Ratings (AAR): an item response theory analysis.

The Adult Attachment Ratings (AAR) include 3 scales for anxious, ambivalent attachment (excessive dependency, interpersonal ambivalence, and compulsive care-giving), 3 for avoidant attachment (rigid self-control, defensive separation, and emotional detachment), and 1 for secure attachment. The scales include items (ranging from 6-16 in their original form) scored by raters using a 3-point format (0 = absent, 1 = present, and 2 = strongly present) and summed to produce a total score. Item response theory (IRT) analyses were conducted with data from 414 participants recruited from psychiatric outpatient, medical, and community settings to identify the most informative items from each scale. The IRT results allowed us to shorten the scales to 5-item versions that are more precise and easier to rate because of their brevity. In general, the effective range of measurement for the scales was 0 to +2 SDs for each of the attachment constructs; that is, from average to high levels of attachment problems. Evidence for convergent and discriminant validity of the scales was investigated by comparing them with the Experiences of Close Relationships-Revised (ECR-R) scale and the Kobak Attachment Q-sort. The best consensus among self-reports on the ECR-R, informant ratings on the ECR-R, and expert judgments on the Q-sort and the AAR emerged for anxious, ambivalent attachment. Given the good psychometric characteristics of the scale for secure attachment, however, this measure alone might provide a simple alternative to more elaborate procedures for some measurement purposes. Conversion tables are provided for the 7 scales to facilitate transformation from raw scores to IRT-calibrated (theta) scores.

Emotion dysregulation as a maintenance factor of borderline personality disorder features.

We examined within-individual changes in emotion dysregulation over the course of one year as a maintenance factor of borderline personality disorder (BPD) features. We evaluated the extent to which (1) BPD symptom severity at baseline predicted within-individual changes in emotion dysregulation and (2) within-individual changes in emotion dysregulation predicted four BPD features at 12-month follow-up: affective instability, identity disturbances, negative relationships, and impulsivity. The specificity of emotion dysregulation as a maintaining mechanism of BPD features was examined by controlling for a competing intervening variable, interpersonal conflict. BPD symptoms at baseline predicted overall level and increasing emotion dysregulation. Additionally, increasing emotion dysregulation predicted all four BPD features at 12-month follow-up after controlling for BPD symptoms at baseline. Further, overall level of emotion dysregulation mediated the association between BPD symptom severity at baseline and both affective instability and identity disturbance at 12-month follow-up, consistent with the notion of emotion dysregulation as a maintenance factor. Future research on the malleability of emotion dysregulation in laboratory paradigms and its effects on short-term changes in BPD features is needed to inform interventions.

Preoccupied attachment and emotional dysregulation: specific aspects of borderline personality disorder or general dimensions of personality pathology?

Emotional dysregulation and impaired attachment are seen by many clinical researchers as central aspects of borderline personality disorder (BPD). Alternatively, these constructs may represent general impairments in personality that are nonspecific to BPD. Using multitraitmultimethod models, the authors examined the strength of associations among preoccupied attachment, difficulties with emotion regulation, BPD features, and features of two other personality disorders (i.e., antisocial and avoidant) in a combined psychiatric outpatient and community sample of adults. Results suggested that preoccupied attachment and difficulties with emotion regulation shared strong positive associations with each other and with each of the selected personality disorders. However, preoccupied attachment and emotional dysregulation were more strongly related to BPD features than to features of other personality disorders. Findings suggest that although impairments in relational and emotional domains may underlie personality pathology in general, preoccupied attachment and emotional dysregulation also have specificity for understanding core difficulties in those with BPD.

Clarifying interpersonal heterogeneity in borderline personality disorder using latent mixture modeling.

Significant interpersonal impairment is a cardinal feature of borderline personality disorder (BPD). However, past research has demonstrated that the interpersonal profile associated with BPD varies across samples, which is evidence for considerable interpersonal heterogeneity. The current study used inventory of interpersonal problems-circumplex (IIP-C; Alden, Wiggins, & Pincus, 1990) scale scores to investigate interpersonal inhibitions and excesses in a large sample (N = 255) selected for significant borderline pathology. Results indicated that BPD symptom counts were unrelated to the primary dimensions of the IIPC, but were related to generalized interpersonal distress. A latent class analysis clarified this finding by revealing six homogeneous interpersonal classes with prototypical profiles associated with Intrusive, Vindictive, Avoidant, Nonassertive, and moderate and severe Exploitable interpersonal problems. These classes differed in clinically relevant features (e.g., antisocial behaviors, self-injury, past suicide attempts). Findings are discussed in terms of the incremental clinical utility of the interpersonal circumplex model and the implications for developmental and nosological models of BPD.

Can DSM-IV borderline personality disorder be diagnosed via dimensional personality traits? Implications for the DSM-5 personality disorder proposal.

The proposal for the diagnosis of personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5;American Psychiatric Association, in preparation) involves, in part, the use of elevated scores on dimensional personality traits. For instance, the diagnosis of borderline personality disorder (BPD) in the DSM-5 will require evidence of self- and interpersonal impairment as well as elevated scores on traits of emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk taking, and hostility. Using a sample of individuals from the community (N = 134), half of whom were receiving psychiatric treatment, we tested whether the summation of relevant personality trait scores, using data derived from a measure of the Five-Factor Model of personality (FFM), would result in a construct that corresponds to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV, American Psychiatric Association, 2000) BPD construct as scored by expert consensus ratings. The DSM-IV and FFM BPD scores were significantly correlated (r = .60) and generated highly similar patterns of relations (ricc = .84) with key constructs from BPD's nomological network. These data should serve to allay concerns that the DSM-5's new diagnostic approach will be detrimental to the identification of BPD.