An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial.

INTRODUCTION: Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings. METHODS AND ANALYSIS: We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness. ETHICS AND DISSEMINATION: Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Criterion a of the alternative model of personality disorders: Structure and validity in a community sample.

The alternative model of personality disorders were designed to represent the presence of personality dysfunction (Criterion A) and pathological personality traits (Criterion B). Much of the empirical attention toward this model has been directed toward testing the performance of Criterion B. However, the development of the Levels of Personality Functioning Scale-Self-Report (LPFS-SR) has sparked a growing amount of interest and debate around Criterion A. Specifically, there is significant disagreement in the research examining the validity of the LPFS-SR, with ongoing discrepancies regarding the measure's underlying structure and measurement of Criterion A. The present study aimed to compare four models (one-factor, four-factor, higher order, and bifactor models) in a sample of 416 adults (49.5% women, 63.5% White) to better understand the structure of the LPFS-SR. This study also built on existing efforts to establish convergent and divergent validity of the LPFS-SR by examining how criteria are related to independent measures of both self and interpersonal pathology. The results from the present study supported a bifactor model. Additionally, the four subscales of the LPFS-SR each captured unique variance above and beyond the general factor. Structural equation models predicting identity disturbance and interpersonal traits demonstrated that while the strongest relationships were found between the general factor and the scales, some support was found for the convergent and discriminant validity of the four factors. This work advances our understanding of the LPFS-SR and provides support for the LPFS-SR as a valid marker of personality pathology in clinical and research settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Longitudinal pathways between suicidal ideation and life stress.

While much research exists linking stress and suicidality in cross-sectional paradigms, little is known regarding the longitudinal interplay of stress and suicidality across time. In addition, less research exists on suicidal ideation - a transdiagnostic precursor to suicidal behavior. Two competing, though not mutually exclusive, explanations relate to stress exposure, where stress causes suicidal ideation, and stress generation, where suicidal ideation causes stress. The present study examined 101 adults self-reporting symptoms of borderline personality disorder. Participants completed a self-report measure of suicidal ideation and a life stress interview in a three-wave design over the course of one year. Cross-lagged panel analyses were used to examine the longitudinal relationships between suicidal ideation and interpersonal/non-interpersonal chronic life stress, as well as dependent/interpersonal episodic life stress. Results supported chronic and episodic interpersonal stress generation for suicidal ideation, although not across all timepoints.

General and body-related self-conscious emotions predict facets of restrictive eating in undergraduate women.

It is well understood that mood intolerance is a predictor of eating disorder (ED) symptoms. However, it is unclear whether intolerance of specific emotional experiences predicts ED symptoms. The current study used an ecological momentary assessment design to assess associations between the intensity and intolerance of general and body-related self-conscious emotions and facets of restrictive eating. Participants were 151 female undergraduate students (Mage = 18.99, SD = 1.30 years) who completed six surveys per day for 10 consecutive days. Participants reported on the intensity and intolerance of general and body-related shame, guilt, envy, and embarrassment and cognitive restraint (thoughts about restrictive eating) and behavioral restriction (act of restrictive eating) facets of restrictive eating. Data were analyzed using multilevel modeling. Based on the between-person findings, participants higher on intensity and intolerance of general and body-related self-conscious emotions experienced higher levels of cognitive restraint and behavioral restriction relative to individuals with lower levels of the emotion intensity and intolerance predictors on average. Based on the within-person findings, experiencing a higher intolerance of body-related self-conscious emotions compared to one's average was particularly important when examining behavioral restriction. Experiencing a higher intolerance of body-related envy was able to predict increased behavioral restriction at the time of the next report. These findings may inform tailored treatment targets for mood intolerance and restrictive eating.

Bridging development and disturbance: A translational approach to the study of identity.

Across the subdisciplines of personality and clinical psychology, identity has been a psychological construct of wide-reaching importance in understanding both normative processes of human development as well as psychopathology. However, despite its wide-reaching importance, differences in the conceptualization and measurement of identity across these subdisciplines have contributed to more fragmentation, rather than unification, in our understanding of this central principle. In the present study, we sought to unify the measurement of identity across these subdisciplines through examining the extent to which personality and clinical measures of identity converge, as well as the predictive validity of identity measures across layers of personality functioning, employing a unique design for a dynamic assessment of identity. Our results supported a 1-factor model, as opposed to a 2-factor model, of identity. This Identity/Identity Dysfunction factor was significantly associated with mean-level neuroticism, extraversion, and agreeableness, but not significantly associated with stability of personality trait expression. It was also associated with more extrinsic values and aspirations, and the stability of extrinsic aspirations. Finally, the Identity/Identity Dysfunction factor demonstrated moderate and negative relationships with indices of narrative coherence. Our results suggest that identity falls along a continuum of development and disturbance and is meaningfully connected to all layers of personality functioning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Measuring Negative Emotion Differentiation Via Coded Descriptions of Emotional Experience.

Emotion differentiation (ED) has been defined in terms of two abilities: (a) making fine-grained distinctions between emotional experiences, and (b) describing individual emotional experiences with a high degree of nuance and specificity. Research to date has almost exclusively focused on the former, with little attention paid to the latter. The current study sought to address this discrepant focus by testing two novel measures of negative ED (i.e., based on negatively valenced emotions only) via coded open-ended descriptions of individual emotional experiences, both past and present. As part of a larger study, 307 participants completed written descriptions of two negative emotional experiences, as well as a measure of emotion regulation difficulties and indices of psychopathological symptom severity. Negative ED ability, as measured via consistency between emotional experiences, was found to be unrelated to negative ED ability exhibited via coding of language within experiences. Within-experience negative ED may offer an incrementally adaptive function to that of ED between emotional experiences. Implications for ED theory are discussed.

The after-effects of momentary suicidal ideation: A preliminary examination of emotion intensity changes following suicidal thoughts.

Research using ecological momentary assessments has highlighted the importance of negative emotions as predictors of day-to-day suicidal thoughts. Yet only one study has examined the real-time consequences of these thoughts. This preliminary investigation examined changes in emotion intensity following suicidal thoughts. It also explored associations between these changes and endorsement of suicide functions as an escape and/or as a solution, examined both as momentary thoughts and intractable beliefs about suicide. Thirty-nine community participants endorsing suicidal ideation were followed for two-weeks and completed multiple daily surveys related to suicidal thoughts, functions of suicide, and emotion intensity. Participants reported heightened emotion intensity immediately following a suicidal thought across six emotions, with delayed reductions in stress and anxiety following ideation onset. When assessed in the moment, suicide as a solution to a problem predicted increases in hopelessness, sadness, stress and general negative affect immediately following a thought, while suicide as an escape predicted increases in anger immediately after a thought. When measured as intractable beliefs, only stronger belief in suicide as a solution to a problem predicted delayed reductions in stress following ideation. Increased intensity of negative emotions immediately following suicidal ideation suggests a potential vicious cycle of heightened emotion intensity and suicidality.

Facial Emotion Perception in Families Affected With Borderline Personality Disorder.

Emotion perception biases may precipitate problematic interpersonal interactions in families affected with borderline personality disorder (BPD) and lead to conflictual relationships. In the present study, the authors investigated the familial aggregation of facial emotion recognition biases for neutral, happy, sad, fearful, and angry expressions in probands with BPD (n = 89), first-degree biological relatives (n = 67), and healthy controls (n = 87). Relatives showed comparable accuracy and response times to controls in recognizing negative emotions in aggregate and most discrete emotions. For sad expressions, both probands and relatives displayed slower response latencies, and they were more likely than controls to perceive sad expressions as fearful. Nonpsychiatrically affected relatives were slower than controls in responding to negative emotional expressions in aggregate, and fearful and sad facial expressions more specifically. These findings uncover potential biases in perceiving sad and fearful facial expressions that may be transmitted in families affected with BPD.

An Examination of Stress Generation and Stress Exposure Models in Relation to Symptoms of Borderline Personality Disorder.

Research examining life stress as a precipitant, co-occurrence, and consequence of psychopathology often has implications for two explanatory models: stress exposure, where stress causes symptoms, and stress generation, where symptoms cause stress. Preliminary evidence suggests that both processes are evident in borderline personality disorder (BPD). The present study examined 101 adults who self-reported at least three symptoms of BPD at prescreen, with 30% of the sample meeting full diagnostic criteria for BPD. Cross-lagged panel analyses were used to examine the relationships between BPD symptomatology and four forms of life stress. Stress exposure and stress generation were not supported for either form of chronic life stress. Results supported stress generation in both dependent and interpersonal episodic life stress, and stress exposure for interpersonal episodic life stress. These findings evidenced small effects only. Findings point to the impact of interpersonal stress on changes in symptomatology over time.

Attrition and attendance in group therapy for university students: An examination of predictors across time.

OBJECTIVES: There exists a dearth of research focused explicitly on predictors of attrition, particularly in the area of group therapy, where both attrition and attendance becomes of primary concern. The present study examined both pretreatment and treatment-specific variables in the prospective prediction of attendance and attrition in group therapy. METHOD: Fifty-two participants were randomized to one of two 12-week group treatments. Participants completed baseline interviews and questionnaires, as well as weekly assessments of treatment-specific factors. RESULTS: No pretreatment factors predicted attendance or drop out, although men attended a larger amount of sessions and were less likely to drop out. Cross-lagged panel analyses supported bidirectional, causal relationships both treatment-specific predictors (therapeutic alliance and number of therapeutic techniques) and attendance. CONCLUSIONS: Successful retention in group therapy may be less predictable from pretreatment factors and instead lie in increasing alliance and fostering the practice of therapeutic strategies.

Evaluating the associations between personality psychopathology and heterogeneous eating disorder behaviors: A dimensional approach.

Studies examining the associations between categorical assessments of eating disorders (ED) and personality have produced some inconsistent findings. The present study aimed to clarify these inconsistencies by implementing a dimensional approach when assessing ED behaviors and personality psychopathology. Associations between pathological personality trait facets and heterogeneous ED behaviors (i.e., restriction, compensatory behaviors, and binge eating) were examined. Participants were 570 community adults (247 women) recruited through Mechanical Turk. The Personality Inventory for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PID-5), was used to assess the pathological personality trait facets. Items from two validated eating pathology scales were used to measure ED behaviors. Two structural equation models-an exploratory model and a theoretical model-were tested for each ED behavior. The exploratory model allowed all PID-5 personality facets to predict the ED behaviors. The theoretical models estimated paths from specific PID-5 facets to the ED behaviors. The theoretical model was an attempt to corroborate previous literature where distinct personality profiles have distinguished individuals with different EDs. The theoretical model was considered the most parsimonious model for all three ED behaviors, and each theoretical model revealed a pattern of significant associations with personality trait facets-restriction was significantly associated with higher rigid perfectionism, and binge eating was significantly associated with higher impulsivity and anxiousness. Only the significant associations with binge eating remained statistically significant when men and women were examined separately. When a dimensional model is applied, significant relationships emerge between heterogeneous ED behaviors and PID-5 trait facets. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

It's the thought that counts: belief in suicide as an escape moderates the relationship between emotion dysregulation and suicidal ideation cross-sectionally and longitudinally.

BACKGROUND: Previous research has illustrated a relationship between emotion dysregulation and suicidal ideation, both cross-sectionally and longitudinally. However, it is not yet understood how this relationship manifests. The aim of this study was to explore if two beliefs about suicide, (1) suicide as a way to escape from emotional pain and (2) suicide as a solution to a problem, moderate the relationship between emotion dysregulation and suicidal ideation. METHODS: One hundred one community participants completed questionnaires examining emotion dysregulation, suicidal ideation, and beliefs in the functions of suicide. Inclusion criteria were used to over-sample individuals within the community experiencing higher levels of suicidal ideation and emotion dysregulation. Hierarchical linear regressions with interaction terms were used to assess moderation effects. The moderating role of beliefs in the function of suicide was examined both cross-sectionally and longitudinally. RESULTS: Suicide as an escape significantly moderated the relationship between global emotion dysregulation and suicidal ideation cross-sectionally, while it moderated the relationship between a facet of emotion dysregulation and suicidal ideation longitudinally. Greater endorsement of this belief resulted in a stronger relationship between emotion dysregulation and suicidal ideation. The function of suicide as a solution to a problem did not moderate the emotion dysregulation-suicidal ideation relationship. CONCLUSIONS: These findings underscore the importance of not only addressing emotion dysregulation but also addressing the underlying belief that suicide is an escape in individuals who experience both emotion dysregulation and suicidal ideation. Intervention efforts to address belief in suicide as an escape along with emotion dysregulation are delineated.

Clarifying the interstitial nature of facets from the Personality Inventory for DSM-5 using the five factor model of personality.

Although the higher order structure of the Personality Inventory for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PID-5; Krueger, Derringer, Markon, Watson, & Skodol, 2012), is well-established, the lower order structure and facet-to-domain assignment is inconsistent across studies. Some studies used the five-factor model of adaptive personality (FFM) as a framework to evaluate and characterize this lower order structure; however, findings have been limited in various respects including the use of primarily Caucasian and nonclinical samples. The goal of the current investigation was to clarify and extend knowledge of the lower order structure of the PID-5 through joint PID-5/FFM analysis using an ethnically diverse undergraduate sample (N = 492) and psychiatric patient sample (N = 388). Our findings revealed an optimal five-factor structure in the undergraduate sample (in which Openness facets did not load on any factor) and a six-factor structure in the clinical sample (in which Openness formed its own factor). Domains displayed good convergent validity with the domains of the personality psychopathology five model, except for Disinhibition/Conscientiousness, in which the lack of convergence was explained by Conscientiousness. Furthermore, we evaluated six specific PID-5 facets with respect to interstitiality and optimal PID-5 domain placement, where results supported several recommendations for model modification of the PID-5 structure. These include moving Restricted Affectivity to Detachment from Negative Affectivity, moving Hostility to Antagonism from Negative Affectivity, moving Suspiciousness to Negative Affectivity from Detachment, and removing Submissiveness from the PID-5 measure and the alternative model of personality disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cross-validation of the demoralization construct in the Revised NEO Personality Inventory.

Demoralization is defined as a pervasive, generalized negative emotional construct present in psychiatric disorders and a variety of medical conditions. Demoralization is also conceptualized as a ubiquitous affective-laden factor common to most forms of psychopathology that increases the magnitude of intercorrelations among putatively distinct psychiatric symptom scales (Tellegen, 1985). Using exploratory structural equation modeling to identify common variance across the revised NEO Personality Inventory (NEO PI-R), a measure of the five-factor model of personality, Noordhof, Sellbom, Eigenhuis, and Kamphuis (2015) constructed an 18-item Demoralization subscale in a Dutch-speaking sample of patients attending a clinic for personality disorders in the Netherlands. In the current study we sought to cross-validate these findings in an English-speaking and diagnostically heterogeneous sample of psychiatric patients (N = 1930) receiving consultation or treatment at a large mental health and addiction center in Canada. Our results support the construct validity of the Demoralization subscale and its capacity to account for demoralization-related variance in the NEO PI-R. We believe these findings support the general tenets of demoralization and the presence of this construct in the NEO PI-R item pool. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mechanisms of change in group therapy for treatment-seeking university students.

The present study examined mechanisms of change in dialectical behavior therapy (DBT) skills group and positive psychotherapy (PPT) group intervention, two treatments that have previously been shown to be effective at reducing symptoms of BPD and depression over a 12-week treatment protocol within the context of a college counseling center (Uliaszek et al., 2016). The present study is secondary data analysis of that trial. We hypothesized that change in dysfunctional coping skills use would be a specific mechanism for DBT, while change in functional coping skills use and therapeutic alliance would be mechanisms of change for both treatments. Fifty-four participants completed self-report and interview-based assessments at pretreatment, weeks 3, 6, 9, and posttreatment. Path models examined the predictive power of the mechanisms in predicting outcome; the moderating effect of group membership was also explored. Dysfunctional coping skills use across the course of treatment was a significant mechanism of change for BPD and depression for the DBT group, but not the PPT group. Conversely, therapeutic alliance was a significant mechanism of change for the PPT group, but not the DBT group. Findings highlight the importance of each mechanism during mid-to late-treatment specifically.

More is not always better: Strategies to regulate negative mood induction in women with borderline personality disorder and depressive and anxiety disorders.

Individuals with borderline personality disorder (BPD) have difficulties regulating emotions, which may be a consequence of using less effective emotion regulation (ER) strategies to lessen the intensity of their negative emotions. It is not yet known whether people with BPD utilize particular ER strategies to modulate specific mood states and if these strategies are different from those used by individuals with depressive and anxiety disorders. In the present study, 90 participants (30 BPD, 30 anxiety and/or depressive disorders, and 30 healthy controls) underwent a mood induction procedure and specified which ER strategies they used and their perceived difficulty regulating mood following induction. Compared with healthy controls, BPD endorsed higher negative mood prior to, immediately following, and 4 min after neutral and negative mood inductions; more maladaptive ER strategies (e.g., rumination); and more perceived difficulty regulating negative mood. Compared with anxiety and/or depressive disorders, BPD endorsed similar ER strategies and subjective difficulty during mood inductions, endorsed higher negative mood following a neutral video and 1 negative video, and recorded higher RSA reactivity during and following 2 negative videos. Results suggest that individuals with BPD use a higher number of maladaptive ER strategies compared with healthy controls, which may lead to less effective modulation of negative mood and higher reports of difficulty regulating emotions. In addition, physiological measurements indicated that individuals with BPD may have higher RSA reactivity in response to negative mood induction compared with other mental disorders, which may reflect inefficient or disorganized attempts to regulate emotional arousal. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Cognitive Emotion Regulation Strategies in Borderline Personality Disorder: Diagnostic Comparisons and Associations with Potentially Harmful Behaviors.

BACKGROUND: Although difficulties in emotion regulation (ER) are considered a core feature of borderline personality disorder (BPD), the specific strategies that individuals with BPD most commonly use, their diagnostic specificity, and their associations with harmful behaviors have not been firmly established. SAMPLING AND METHODS: Individuals with BPD (n = 30), mixed anxiety and/or depressive disorders (MAD; n = 30), and healthy controls (HC; n = 32) completed questionnaires assessing both cognitive ER strategies (e.g., cognitive reappraisal) and potentially harmful behaviors that individuals might use to regulate their emotions (e.g., self-injury). RESULTS: BPD subjects endorsed more maladaptive cognitive ER strategies and fewer adaptive strategies compared to HC. Compared to MAD subjects, BPD individuals endorsed more maladaptive cognitive ER strategies, but only when those with subthreshold symptoms in the MAD group were excluded. BPD also endorsed engaging in potentially harmful behaviors more often than both HC and MAD. Discriminant analysis revealed that MAD endorsed lower rates of problem-solving and cognitive reappraisal compared to both HC and BPD. Higher maladaptive and lower adaptive ER strategies were associated with higher rates of potentially harmful behaviors, although the specific strategies differed for MAD versus BPD. CONCLUSIONS: BPD and MAD endorse cognitive ER strategies with a comparable frequency, although BPD subjects engage in potentially harmful behaviors more often. Subthreshold BPD symptoms may also affect rates of ER strategy use in individuals with other mental disorders.

Changes in Neurocognitive Functioning After 6 Months of Mentalization-Based Treatment for Borderline Personality Disorder.

Patients with borderline personality disorder (BPD) have deficits in neurocognitive function that could affect their ability to engage in psychotherapy and may be ameliorated by improvements in symptom severity. In the current study, 18 patients with BPD completed neurocognitive tests prior to beginning mentalization-based therapy and again after 6 months of treatment. Twenty-eight nonpsychiatric controls were tested over the same period of time but received no intervention. Before starting treatment, patients performed lower than controls on tests assessing sustained attention and visuospatial working memory. After 6 months of treatment, patients showed significantly greater increases in sustained attention and perceptual reasoning than controls, with initial deficits in sustained attention among patients resolving after treatment. Improved emotion regulation over the follow-up period was associated with increased auditory-verbal working memory capacity, whereas interpersonal functioning improved in parallel with perceptual reasoning. These findings suggest that changes in neurocognitive functioning may track improvements in clinical symptoms in mentalization-based treatment for BPD.

Therapeutic alliance mediates the association between personality and treatment outcome in patients with major depressive disorder.

BACKGROUND: Patient personality traits have been shown to influence treatment outcome in those with major depressive disorder (MDD). The trait agreeableness, which reflects an interpersonal orientation, may affect treatment outcome via its role in the formation of therapeutic alliance. No published studies have tested this hypothesis in patients with MDD. METHOD: Participants were 209 outpatients with MDD who were treated in a randomized control trial. Mediation analyses were conducted to examine the role of therapeutic alliance in the association between pretreatment personality and the reduction of depression symptom severity during treatment. Separate models were estimated for patient- versus therapist-rated therapeutic alliance. RESULTS: We found a significant indirect effect of agreeableness on the reduction of depression severity via patient-rated therapeutic alliance. Results were replicated across two well-validated measures of depression symptom severity. Results also partially supported indirect effects for extraversion and openness. Therapist ratings of alliance did not mediate the association between personality and treatment outcomes. LIMITATIONS: Patients were recruited as part of a randomized control trial, which may limit the generalizability of results to practice-based clinical settings. Due to constraints on statistical power, intervention-specific mediation results were not examined. CONCLUSIONS: These results highlight the importance of personality and the role it plays in treatment process as well as outcome.

Group therapy for university students: A randomized control trial of dialectical behavior therapy and positive psychotherapy.

The present study examined the efficacy of two evidence-based group treatments for significant psychopathology in university students. Fifty-four treatment-seeking participants were randomized to a semester-long dialectical behavior therapy (DBT) or positive psychotherapy (PPT) group treatment. Mixed modeling was used to assess improvement over time and group differences on variables related to symptomatology, adapative/maladaptive skill usage, and well-being/acceptability factors. All symptom and skill variables improved over the course of treatment. There were no statistically significant differences in rate of change between groups. The DBT group evidenced nearly all medium to large effect sizes for all measures from pre-to post-treatment, with mostly small to medium effect sizes for the PPT group. There was a significant difference in acceptability between treatments, with the DBT group demonstrating significantly lower attrition rates, higher attendance, and higher overall therapeutic alliance. While both groups demonstrated efficacy in this population, the DBT group appeared to be a more acceptable and efficacious treatment for implementation. Results may specifically apply to group therapy as an adjunctive treatment because a majority of participants had concurrent individual therapy.