Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT).

INTRODUCTION: Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT. OBJECTIVE: The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD. METHODS: Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037. RESULTS: Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056). CONCLUSION: Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

The difference between shorter- versus longer-term psychotherapy for adult mental health disorders: a systematic review with meta-analysis.

BACKGROUND: The optimal psychotherapy duration for mental health disorders is unclear. Our aim was to assess the beneficial and harmful effects of shorter- versus longer-term psychotherapy for adult mental health disorders. METHOD: We searched relevant databases and websites for published and unpublished randomised clinical trials assessing different durations of the same psychotherapy type before June 27, 2022. Our methodology was based on Cochrane and an eight-step procedure. Primary outcomes were quality of life, serious adverse events, and symptom severity. Secondary outcomes were suicide or suicide-attempts, self-harm, and level of functioning. RESULTS: We included 19 trials randomising 3,447 participants. All trials were at high risk of bias. Three single trials met the required information size needed to confirm or reject realistic intervention effects. One single trial showed no evidence of a difference between 6 versus 12 months dialectical behavioral therapy for borderline personality when assessing quality of life, symptom severity, and level of functioning. One single trial showed evidence of a beneficial effect of adding booster sessions to 8 and 12 weeks of internet-based cognitive behavioral therapy for depression and anxiety when assessing symptom severity and level of functioning. One single trial showed no evidence of a difference between 20 weeks versus 3 years of psychodynamic psychotherapy for mood- or anxiety disorders when assessing symptom severity and level of functioning. It was only possible to conduct two pre-planned meta-analyses. Meta-analysis showed no evidence of a difference between shorter- and longer-term cognitive behavioural therapy for anxiety disorders on anxiety symptoms at end of treatment (SMD: 0.08; 95% CI: -0.47 to 0.63; p = 0.77; I2 = 73%; four trials; very low certainty). Meta-analysis showed no evidence of a difference between shorter and longer-term psychodynamic psychotherapy for mood- and anxiety disorders on level of functioning (SMD 0.16; 95% CI -0.08 to 0.40; p = 0.20; I2 = 21%; two trials; very low certainty). CONCLUSIONS: The evidence for shorter versus longer-term psychotherapy for adult mental health disorders is currently unclear. We only identified 19 randomised clinical trials. More trials at low risk of bias and at low risk of random errors assessing participants at different levels of psychopathological severity are urgently needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019128535.

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study.

PURPOSE: Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia. METHOD AND MATERIALS: In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending. RESULTS: Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles. CONCLUSIONS: Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

National norms of mental health for Denmark.

INTRODUCTION: To facilitate interpretation and clinical utility of patient-reported outcomes, normative data provide a reference for a person's score on a particular outcome in relation to the general population. This study reports Danish general population norms for four mental health indicators, assessing social functioning (Sheehan Disability Scale, SDS) personal recovery (Brief INSPIRE-O), symptom burden (Symptom Check List-10, SCL-10) and subjective well-being (WHO-5). METHODS: The study was a cross-sectional survey study organized by the State's statistical authority among the general population of adult Danish residents in Denmark, ranging in age between 18 to 79 years. RESULTS: A total of 8003 citizens were contacted including reminders from 2 March 2019 to 11 April 2019 by electronic letters, resulting in 2819 (35%) citizens providing complete responses. Female gender, higher age, Danish origin and living with a partner were associated with increased participation, and decreased participation was observed in male immigrants. We found a mean score of subjective well-being slightly lower than the population norm typically found in Danish general population studies. Elderly persons, Danes, and persons living with a partner reported better subjective mental health. Subjective well-being and personal recovery were positively correlated with social contacts and self-reported general health rating, and negatively correlated with social functioning and symptoms of depression and anxiety. CONCLUSION: This normative data provides a reference for interpreting mental health status. Our findings indicate slightly poorer subjective mental health than previously found. There is a need for special attention to engaging male immigrants in studies on mental health in the general population.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study.

ABSTRACT: Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

A clinical illustration of short-term mentalization-based therapy for borderline personality disorder.

OBJECTIVE: Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format. METHODS: Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety. RESULTS: The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning. CONCLUSIONS: Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode".

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Level of alexithymia as a measure of personality dysfunction in avoidant personality disorder.

BACKGROUND AND OBJECTIVES: Avoidant Personality Disorder (AvPD) is considered a mild to moderate personality disorder. However, few studies have focused on the heterogeneity of AvPD in terms of symptoms and severity. In the current study we set out to replicate and extend earlier findings showing that there is variation among patients with AvPD in terms of alexithymia and, further, that this variation is especially associated with specific facets of personality functioning and is not explained by measures of depression, symptom severity, or co-occurring personality disorder traits. METHOD: We used intake data from a sample of AvPD patients (n = 56) who had been treated in similar outpatient services. Alexithymia was measured using the Toronto Alexithymia Scale (TAS-20). Patients filled out questionnaires that were analysed using linear regression models. RESULTS AND CONCLUSIONS: Using well-established cut-off points for low, intermediate and high levels of alexithymia we found an almost equal distribution of alexithymia groups in our sample. Alexithymia was associated with higher personality dysfunction on twelve out of sixteen facets of personality functioning. For eight of these personality facets the alexithymia total score explained significant variance even after controlling for self-reported depression, symptom severity and clinician ratings of personality disorder. Results suggest that AvPD is heterogeneous and that alexithymia may be important as an indicator of severity of specific personality dysfunction.

Awakening to recognize the detrimental effects of social avoidance and the possibility of healing through reconnection.

BACKGROUND: Loneliness and social avoidance are widespread and serious mental health problems. People experiencing loneliness or social avoidance have difficulties maintaining ordinary life activities and often experience profound suffering. How do we as clinicians deal with or help people out of loneliness and social avoidance? AIMS: In this paper, we introduce the issue on loneliness and social avoidance. We do so by first defining loneliness and social avoidance and outlining the impact on mental health issues of these phenomena. Next, we introduce the six papers central to the special issue along with some thoughts on how to understand therapy and treatment of social avoidance. DISCUSSION: We discuss new directions and how to move beyond more conventional therapeutic approaches to these problems.

Incorporating narrative repair in the treatment of avoidant personality disorders: A case in point.

Avoidant personality disorder (AvPD) is characterized by multiple struggles, including shyness, feelings of inadequacy, and hypersensitivity to interpersonal judgments. Research indicates that people with AvPD also show disturbances in narrative identity, which is an internal and evolving story created about the personal past, present, and presumed future. Here, the novel Guide for Narrative Repair (GNaR) recently developed by (Thomsen et al., 2020) is introduced as a potentially useful tool to help people with AvPD in crafting more adaptive narrative identities. The guide is brought to life via a case study analysis of Adam, a male outpatient suffering from AvPD. Consistent with the GNaR, disturbances in Adam's storied self are brought to light and ways to facilitate his narrative repair are proposed. We conclude with implications related to the case as well as the potential narrative turn in AvPD treatment.

Personal and parents' life stories in patients with borderline personality disorder.

Patients with borderline personality disorder (BPD) display disturbances in understanding self and others. We examined whether these disturbances extended to how patients described their personal and parents' life stories and to measures of identity, alexithymia, empathy, and emotional intelligence. Thirty BPD patients and 30 matched control participants described personal and parents' life stories and completed measures of identity disturbance, alexithymia, empathy, and emotional intelligence. Compared to the controls, patients with BPD described their personal and their parents' life stories more negatively and with fewer themes of agency and communion fulfillment. Patients and controls showed equally complex reasoning about their personal life stories, but patients displayed less complexity and more self-other confusion, when reasoning about their parents' stories. Patients also differed from controls on identity disturbance, alexithymia, and empathy. The results suggest that patients' storied understanding of themselves and others are disturbed and should be taken into account to better understand BPD.

Laser altimetry reveals complex pattern of Greenland Ice Sheet dynamics.

We present a new record of ice thickness change, reconstructed at nearly 100,000 sites on the Greenland Ice Sheet (GrIS) from laser altimetry measurements spanning the period 1993-2012, partitioned into changes due to surface mass balance (SMB) and ice dynamics. We estimate a mean annual GrIS mass loss of 243 ± 18 Gt ⋅ y(-1), equivalent to 0.68 mm ⋅ y(-1) sea level rise (SLR) for 2003-2009. Dynamic thinning contributed 48%, with the largest rates occurring in 2004-2006, followed by a gradual decrease balanced by accelerating SMB loss. The spatial pattern of dynamic mass loss changed over this time as dynamic thinning rapidly decreased in southeast Greenland but slowly increased in the southwest, north, and northeast regions. Most outlet glaciers have been thinning during the last two decades, interrupted by episodes of decreasing thinning or even thickening. Dynamics of the major outlet glaciers dominated the mass loss from larger drainage basins, and simultaneous changes over distances up to 500 km are detected, indicating climate control. However, the intricate spatiotemporal pattern of dynamic thickness change suggests that, regardless of the forcing responsible for initial glacier acceleration and thinning, the response of individual glaciers is modulated by local conditions. Recent projections of dynamic contributions from the entire GrIS to SLR have been based on the extrapolation of four major outlet glaciers. Considering the observed complexity, we question how well these four glaciers represent all of Greenland's outlet glaciers.

Personality disorders: patient characteristics and level of outpatient treatment service.

BACKGROUND: In this naturalistic study, patients with personality disorders (N = 388) treated at Stolpegaard Psychotherapy Center, Mental Health Services, Capital Region of Denmark were allocated to two different kinds of treatment: a standardized treatment package with a preset number of treatment hours (basic hospital service) and 2: a specialized treatment program for the most severely affected patients without a predetermined restricted number of treatment hours and significantly more individual psychotherapy (regional specialized hospital services). AIMS: To investigate patient characteristics associated with clinicians' allocation of patients to the two different personality disorder services. METHODS: Patient characteristics across eight domains were collected in order to study whether there were systematic differences between patients allocated to the two different treatments. Patient characteristics included measures of symptom severity, personality pathology, trauma and socio-demographic characteristics. Significance testing and binary regression analysis were applied to identify important predictors. RESULTS: Patient characteristics on fifteen variables differed significantly, all in the expected direction, with patients in regional specialized hospital services showing more pathology and psychosocial problems. In the regression model, only age and two variables capturing psychosocial functioning remained significant predictors of allocation. DISCUSSION: The finding that younger age was the most significant predictor of longer treatment replicates an earlier finding of allocation to treatment for personality disorder. Overall, this study therefore lends further support to the importance of demographic and social contextual factors in clinicians' allocation of patients to different treatment services for personality disorder.

Assessment of personality-related levels of functioning: a pilot study of clinical assessment of the DSM-5 level of personality functioning based on a semi-structured interview.

BACKGROUND: The personality disorder categories in the Diagnostic and Statistical Manual of Mental Disorders IV have been extensively criticized, and there is a growing consensus that personality pathology should be represented dimensionally rather than categorically. The aim of this pilot study was to test the Clinical Assessment of the Level of Personality Functioning Scale, a semi-structured clinical interview, designed to assess the Level of Personality Functioning Scale of the DSM-5 (Section III) by applying strategies similar to what characterizes assessments in clinical practice. METHODS: The inter-rater reliability of the assessment of the four domains and the total impairment in the Level of Personality Functioning Scale were measured in a patient sample that varied in terms of severity and type of pathology. Ratings were done independently by the interviewer and two experts who watched a videotaped Clinical Assessment of the Level of Personality Functioning Scale interview. RESULTS: Inter-rater reliability coefficients varied between domains and were not sufficient for clinical practice, but may support the use of the interview to assess the dimensions of personality functioning for research purposes. CONCLUSIONS: While designed to measure the Level of Personality Functioning Scale with a high degree of similarity to clinical practice, the Clinical Assessment of the Level of Personality Functioning Scale had weak reliabilities and a rating based on a single interview should not be considered a stand-alone assessment of areas of functioning for a given patient.

The quest for tailored treatments: a meta-discussion of six social cognitive therapies.

In this commentary on the 6 articles comprising this In Session issue on metacognition and mentalizing in the psychotherapeutic treatment of severe mental disorders, we strive to contextualize and bring together salient issues reflected in these articles. In the foreground of our discussion is the point that the commonalities of these and related social cognitive treatments far outweigh their differences. We attempt to pinpoint some of the more specific tailored treatment elements described by the authors and relate these to empirical findings and theoretical and practical problems. Among the key issues addressed in this commentary are conceptual fallacies, therapist transparency, personality disorder and self-harm in adolescence, therapeutic alliance, and a metacognitive-informed group psychotherapy practice for patients with avoidant personality disorder or alexithymia.

Scalability, test-retest reliability and validity of the Brief INSPIRE-O measure of personal recovery in psychiatric services.

Introduction: Mental health services have transitioned from treating symptoms to emphasizing personal recovery. Despite its importance, integrating personal recovery into clinical practice remains work in progress. This study evaluates the psychometric qualities of the Brief INSPIRE-O, a five-item patient-reported outcome measure assessing personal recovery. Method: The study collected data from 2018 to 2020 at the Mental Health Services, Capital Region of Denmark, using an internet-based system examining 8,192 non-psychotic patients - receiving outpatient treatment. Materials: This study evaluated the Brief INSPIRE-O and used measures of symptomatology (SCL-10), well-being (WHO-5), and social functioning (modified SDS). Results: The study population comprised 76.8% females with a mean age of 32.9 years, and diagnoses included anxiety (28%), depression (34%), and personality disorder (19%). The mean Brief INSPIRE-O score (39.9) was lower than the general population norm (71.1). The Brief INSPIRE-O showed acceptable test-retest reliability (0.75), scalability (0.39), and internal consistency (0.73). Correlations with other mental health criteria were in the expected direction for symptomatology (-0.46), well-being (0.60), and social functioning (-0.43) and remained consistent across diagnoses. Discussion: The Brief INSPIRE-O demonstrated strong psychometric qualities and could be recommended as a measure of personal recovery for use in both research and clinical practice. Its strong theoretical basis and short completion time make it suitable for use for research. Incorporating Brief INSPIRE-O into clinical assessment will further support the process of mental health systems re-orientating towards personal recovery.

Adapting Short-Term Mentalization-Based Therapy to ICD-11 Personality Disorder in Adolescents.

Following the introduction of the 11th revision of the International Classification of Diseases (ICD-11), adolescents can now be diagnosed with a personality disorder based on severity ranging from mild to moderate to severe. This dimensional model has potential implications for treatment, as it allows clinicians and researchers to search for effective treatments targeting adolescents at different severity levels rather than offering all patients the same treatment. In this conceptual paper, we propose that the short-term mentalization-based therapy (MBT) program, originally developed to treat adults with borderline personality disorder (BPD), has potential clinical advantages for adolescents with ICD-11 personality disorder at the mild to moderate severity level. The short-term MBT program is a 5-month structured treatment approach including individual therapy, combined psychotherapy with the individual therapist also being one of the group therapists, and closed-group therapy to enhance cohesion and a feeling of security. The purpose of this paper is to make a case for the use of this format, as opposed to the traditional long-term MBT format, for adolescents with BPD. Future research should include large-scale randomized clinical trials powered to assess patient-important outcomes.

Mentalizing the therapist - Therapist experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study.

Background: Mentalization-Based Therapy (MBT) was originally developed as a structured psychotherapy approach developed to treat borderline personality disorder (BPD) lasting up to 18 months in outpatient settings. However, a short-term (5 months) MBT program has recently been developed. No studies have investigated how MBT therapists experience the shift towards conducting short-term MBT for BPD. Objective: The objective of this study was to explore therapist experiences with conducting short-term MBT for outpatients with BPD in the Danish mental health services. Methods: Semi-structured qualitative interviews were conducted with seven therapists about their experiences with short-term MBT after a one-year pilot phase. The interviews were verbatim transcribed and analyzed using thematic analysis. Results: The following four major themes from the therapists' experiences with short-term MBT were found in the qualitative analysis: (1) The longer the better, (2) Change processes can be intellectual or experiential, (3) Short-term therapy is hard work, and (4) Termination is more challenging in short-term MBT. Conclusion: Most therapists were overall reluctant towards changing from long-term to short-term MBT. These therapist experiences could inform implementation of short-term MBT in mental health settings in the future.

Normative data for the LPFS-BF 2.0 derived from the Danish general population and relationship with psychosocial impairment.

The Level of Personality Functioning Scale-Brief Form 2.0 is a frequently used self-report inventory that may be used to screen for self- and interpersonal dysfunction according to the DSM-5 Alternative Model for Personality Disorders (AMPD) and the ICD-11 Classification of Personality Disorders. Nevertheless, reliable norms and cut-off scores to aid interpretation and clinical decision making are still lacking. The LPFS-BF and relevant impairment measures were administered to a sociodemographically stratisfied sample of 2,002 adults from the general Danish population of whom 713 individuals eventually delivered data for inclusion in the present study. The unidimensionality of the LPFS-BF scores was established using Confirmatory Factor Analysis (CFA). Item-Response Theory (IRT) analysis indicated satisfactory item functioning for all 12 items and suggested normative observed score thresholds at different latent severity levels. Meaningful associations were found between the LPFS-BF norm-based cut-off scores, quality of life, and social and occupational functioning. This study presented the first normative data for LPFS-BF, which specifically applies to Denmark but likely also other socioeconomically comparable Nordic and Western societies. These results allow for interpretation of LPFS-BF scores and clinical decision-making. Future research should corroborate these findings and compare them to scores obtained in other general population samples.

Trauma exposure and diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) posttraumatic stress disorder among Danish adults: Implications of narrow and broad operationalizations of criterion A.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has long been recognized as a debilitating psychiatric disorder. The definition of Criterion A has been a topic of controversy, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and International Classification of Diseases, 11th version have opted for a narrow and a broad approach to the gatekeeper criterion, respectively. The aim of this study was to test the implications of a narrow (DSM-5) versus broad (including psychologically threatening events) Criterion A for endorsement of a probable PTSD diagnosis and symptom severity. METHOD: The study was based on a cross-sectional survey conducted in March 2021 among the general population of adult Danish residents in Denmark, ranging in age between 18 and 79 years (n = 1,033). RESULTS: Psychologically threatening events did not lead to a statistically significant increase in probable PTSD diagnoses, but psychologically threatening events were independently related to probable PTSD risk and severity. Controlling for other potentially traumatizing events and demographic factors, psychologically threatening events were the strongest risk factor for higher symptom severity. We found probable PTSD rates higher but comparable to other Scandinavian countries such as Norway and Sweden. CONCLUSION: Exposure to psychologically threatening events is an important factor in explaining probable PTSD risk and severity although not independently leading to a significant increase in probable PTSD rates. Probable rates of DSM-5 PTSD are higher than Danish official estimates in a random sample of the Danish adult population (6.8%-6.9% compared to 1%). The generalizability of study findings is limited by nonrepresentativity, the use of self-report measures, and assessment during the COVID-19 lockdown. (PsycInfo Database Record (c) 2023 APA, all rights reserved).