Reliability and validity of the DBT-VLCS: A measure to code validation strategies in dialectical behavior therapy sessions.

OBJECTIVE: There are six strategies or validation levels in dialectical behavior therapy (DBT), yet there are no measures designed to code for them. This absence limits our understanding of the relationship between validation strategies and treatment outcome. The DBT-Validation Level Coding Scale (DBT-VLCS) was developed to overcome this limitation. METHOD: This research reports on the interrater reliability and content validity for the DBT-VLCS. RESULTS: Overall, interrater reliability was excellent for all items, with the exception of two items that demonstrated good reliability. Good content validity was demonstrated for six of the seven items. CONCLUSIONS: This preliminary study suggests that the DBT-VLCS is a reliable and valid measure to code the presence of validation in DBT. This measure creates the opportunity for research that has not previously been possible.

Emotional cascades and self-injury: investigating instability of rumination and negative emotion.

OBJECTIVE: Nonsuicidal self-injury (NSSI) is a public health concern and risk factor for suicide. The Emotional Cascade Model (ECM) proposes that NSSI partially functions as a distraction from cascades of negative affect and rumination. The purpose of this study was to examine the roles of trait rumination, and momentary instability of rumination and negative emotion, in NSSI. METHOD: Experience sampling methods were used to monitor thoughts, emotions, and behaviors in 47 individuals reporting dysregulated behaviors including NSSI. Instability indices were generated for rumination and negative emotion using the momentary assessments. RESULTS: Twenty-five episodes of NSSI were reported during monitoring. Trait rumination prospectively predicted NSSI episodes, and the instability indices interacted to predict NSSI. CONCLUSIONS: Consistent with the ECM, the interaction between rumination instability and negative affect instability during monitoring significantly predicted NSSI, with the strongest effects occurring for sadness and rumination about past. These findings may enhance conceptualization and treatment of patients with NSSI.

A clinician-administered severity rating scale for illness anxiety: development, reliability, and validity of the H-YBOCS-M.

BACKGROUND: Clinician-administered measures to assess severity of illness anxiety and response to treatment are few. The authors evaluated a modified version of the hypochondriasis-Y-BOCS (H-YBOCS-M), a 19-item, semistructured, clinician-administered instrument designed to rate severity of illness-related thoughts, behaviors, and avoidance. METHODS: The scale was administered to 195 treatment-seeking adults with DSM-IV hypochondriasis. Test-retest reliability was assessed in a subsample of 20 patients. Interrater reliability was assessed by 27 interviews independently rated by four raters. Sensitivity to change was evaluated in a subsample of 149 patients. Convergent and discriminant validity was examined by comparing H-YBOCS-M scores to other measures administered. Item clustering was examined with confirmatory and exploratory factor analyses. RESULTS: The H-YBOCS-M demonstrated good internal consistency, interrater and test-retest reliability, and sensitivity to symptom change with treatment. Construct validity was supported by significant higher correlations with scores on other measures of hypochondriasis than with nonhypochondriacal measures. Improvement over time in response to treatment correlated with improvement both on measures of hypochondriasis and on measures of somatization, depression, anxiety, and functional status. Confirmatory factor analysis did not show adequate fit for a three-factor model. Exploratory factor analysis revealed a five-factor solution with the first two factors consistent with the separation of the H-YBOCS-M items into the subscales of illness-related avoidance and compulsions. CONCLUSIONS: H-YBOCS-M appears to be valid, reliable, and appropriate as an outcome measure for treatment studies of illness anxiety. Study results highlight "avoidance" as a key feature of illness anxiety-with potentially important nosologic and treatment implications.

Is Suicidal Behavior in Mood Disorders Altered by Comorbid PTSD?

BACKGROUND: Suicide is a leading cause of death among US veterans. Associations between depression, posttraumatic stress disorder (PTSD), and suicidal behaviors have been found in this population, yet minimal research has explored how manifestations of self-injurious behavior (SIB) may vary among different diagnostic presentations. AIMS: This study aimed to identify clinically useful differences in SIB among veterans who experience comorbid mood disorder and PTSD (CMP) compared with those who experience a mood disorder alone (MDA). METHOD: Participants were 57 US military veterans who reported an incident of intentional SIB. The semistructured Post Self-Injury/Attempted Self-Injury Debriefing Interview was used to examine characteristics of the SIB. RESULTS: Veterans diagnosed with CMP were more likely than those with MDA to (a) report that the SIB was impulsive and (b) to be under the influence of substances at the time of self-injury. LIMITATIONS: Generalizability may be limited by small sample size and predominantly European American, male demographics. While highly relevant to routine clinical practice, caution is recommended, as study diagnoses were attained from medical records rather than structured interviews. CONCLUSION: Safety planning that emphasizes protection against impulsive suicide attempts (e.g., means restriction) may be especially important among veterans with comorbid mood disorder and PTSD.

The effect of therapist use of validation strategies on change in client emotion in individual dbt treatment sessions.

Dialectical behavior therapy (DBT) is a treatment for borderline personality disorder, a disorder for which emotion dysregulation is central. Within DBT, there are 6 explicitly defined validation strategies that range hierarchically from validation level (VL) 1 to VL 6. To date, there have been no studies on the frequency of use of VLs in actual DBT sessions. The aim of the current study was to explore DBT therapists' use of VLs and examine the relationship between VLs and change in a client emotion during therapy sessions. DBT treatment sessions (n = 121) across 35 participants in a DBT training clinic were coded for therapist use of VLs. A repeated-measures analysis of variance (ANOVA) was used to assess for change in therapist use of VLs over time and hierarchical linear modeling was used to correlate therapist use of these strategies with change in client emotion. Results indicated no significant relationship between overall frequency of VLs and change in client emotion. However, an increase in frequency of high VLs was associated with an increase in positive affect (PA) and a decrease in negative affect (NA) while an increase in frequency of low VLs was associated with a decrease in PA and no change in NA. An increase in frequency of VL 4 was associated with an increase in NA. VL 6 was associated with an increase in PA and a decrease in NA. Findings suggest that specific validation strategies may be related to session changes in affect and have implications for identifying potential mechanisms of change. (PsycINFO Database Record

Suicide attempters with Borderline Personality Disorder show differential orbitofrontal and parietal recruitment when reflecting on aversive memories.

Suicidal behavior and difficulty regulating emotions are hallmarks of Borderline Personality Disorder (BPD). This study examined neural links between emotion regulation and suicide risk in BPD. 60 individuals with BPD (all female, mean age = 28.9 years), 46 of whom had attempted suicide, completed a fMRI task involving recalling aversive personal memories. Distance trials assessed the ability to regulate emotion by recalling memories from a third-person, objective viewpoint. Immerse trials assessed emotional reactivity and involved recalling memories from a first-person perspective. Behaviorally, both groups reported less negative affect on Distance as compared to Immerse trials. Neurally, two sets of findings were obtained. The first reflected differences between attempters and non-attempters. When immersing and distancing, attempters showed elevated recruitment of lateral orbitofrontal cortex, a brain region implicated in using negative cues to guide behavior. When distancing, attempters showed diminished recruitment of the precuneus, a region implicated in memory recall and perspective taking. The second set of findings related to individual differences in regulation success - the degree to which individuals used distancing to reduce negative affect. Here, we observed that attempters who successfully regulated exhibited precuneus recruitment that was more similar to non-attempters. These data provide insight into mechanisms underlying suicide attempts in BPD. Future work may examine if these findings generalize to other diagnoses and also whether prior findings in BPD differ across attempters and non-attempters.