The working mechanisms of imagery rescripting and eye movement desensitization and reprocessing: Findings from a randomised controlled trial.

We studied the mechanisms of eye movement desensitization and reprocessing (EMDR) and imagery rescripting (ImRs). We hypothesized that EMDR works via changes in memory vividness, that ImRs works via changes in encapsulated beliefs (EB), and that both treatments work via changes in memory distress. Patients (N = 155) with childhood-related posttraumatic stress disorder (Ch-PTSD) received 12 sessions of EMDR or ImRs. The vividness, distress, and EB related to the index trauma were measured with the Imagery Interview. PTSD severity was assessed with the Impact of Events Scale-Revised and the Clinician-Administered PTSD Scale for DSM-5. We conducted mixed regressions and Granger causality analyses. EMDR led to initially stronger changes in all predictors, but only for distress this was retained until the last assessment. No evidence for vividness as a predictive variable was found. However, changes in distress and EB predicted changes in PTSD severity during ImRs. These findings partially support the hypothesized mechanisms of ImRs, while no support was found for the hypothesized mechanisms of EMDR. Differences in the timing of addressing the index trauma during treatment and the timing of assessments could have influenced the findings. This study provides insight into the relative effectiveness and working mechanisms of these treatments.

Chairwork in schema therapy for patients with borderline personality disorder-A qualitative study of patients' perceptions.

Objective: Chairwork is one of the core experiential techniques of Schema Therapy (ST) which is used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how people with BPD experience chairwork. The aim of this study was to explore the experiences of patients with BPD with chairwork in ST. Method: Qualitative data were collected through semi-structured interviews with 29 participants with a primary diagnosis of BPD who experienced chairwork as part of their ST treatment. The interview data were analyzed using qualitative content analysis. Findings: Many participants reported initial skepticism, and difficulties with engaging in chairwork. Specific therapist behaviors as well as some external (e.g., restricted facilities, noise) and internal factors (especially feeling ashamed or ridiculous) were named as hindering factors. Participants described several therapist behaviors facilitating chairwork such as providing safety, clear guidance through the process as well as flexible application of the technique according to their needs, and sufficient time for debriefing. Participants experienced emotional pain and exhaustion as short-term effects of the technique. All participants reported positive long-term effects including an improved understanding of their mode model as well as positive mode changes (e.g., less Punitive Parent and more Healthy Adult Mode), greater self-acceptance, improvements in coping with emotions and needs as well as improvements in interpersonal relationships. Conclusions: Chairwork is experienced as an emotionally demanding but valuable technique. Based on the participants' statements, the delivery of chairwork can be optimized which can help to improve treatment outcome.

Intraindividual variability and emotional change as predictors of sudden gains in imagery rescripting and EMDR for PTSD in adult survivors of childhood abuse.

Sudden gains, defined as large and stable improvements in symptom severity during psychological treatment, have consistently been found to be associated with better outcomes across treatments and diagnoses. Yet, insights on coherent predictors of sudden gains and on emotional changes around sudden gains in post-traumatic stress disorder (PTSD) are lacking. We aimed at replicating a measure of intraindividual variability as a predictor for sudden gains and testing its independence from change during treatment. Furthermore, we expected changes in emotions of guilt, shame and disgust prior to sudden gains to predict sudden gains. Data from a pre-registered randomized controlled trial (RCT) of eye-movement desensitization and reprocessing (emdr) and Imagery Rescripting (ImRs) for PTSD in 155 adult survivors of childhood abuse were used. Intraindividual variability of PTSD symptoms in both treatments did not predict sudden gains status and was not independent of change during treatment. In the EMDR condition, levels of shame during treatment predicted sudden gains and shame decreased shortly before a sudden gain in both treatments. Reductions in all emotions during sudden gains were significantly higher for participants with sudden gains than for comparable intervals in non-sudden gainers. Our findings do not support the predictive validity of intraindividual variability for sudden gains. The decrease of guilt, shame and disgust during sudden gains warrants further research on their role as a mechanism of treatment change for PTSD.

The Effectiveness of Metacognitive Therapy Compared to Behavioral Activation for Severely Depressed Outpatients: A Single-Center Randomized Trial.

INTRODUCTION: Major depressive disorder (MDD) is a highly prevalent and disabling disorder. This study examines two psychotherapy methods for MDD, behavioral activation (BA), and metacognitive therapy (MCT), when applied as outpatient treatments to severely affected patients. METHODS: The study was conducted in a tertiary outpatient treatment center. Patients with a primary diagnosis of MDD (N = 122) were included in the intention-to-treat sample (55.7% female, mean age 41.9 years). Participants received one individual and one group session weekly for 6 months (M). Assessments took place at baseline, pretreatment, mid-treatment (3 M), post-treatment (6 M), and follow-up (12 M). The primary outcome was depressive symptomatology assessed by the Hamilton Rating Scale for Depression at 12 M follow-up. Secondary outcomes included general symptom severity, psychosocial functioning, and quality of life. RESULTS: Linear mixed models indicated a change in depressive symptoms (F(2, 83.495) = 12.253, p < 0.001) but no between-group effect (F(1, 97.352) = 0.183, p = 0.670). Within-group effect sizes were medium for MCT (post-treatment: d = 0.610; follow-up: d = 0.692) and small to medium for BA (post-treatment: d = 0.636, follow-up: d = 0.326). In secondary outcomes, there were improvements (p ≤ 0.040) with medium to large within-group effect sizes (d ≥ 0.501) but no between-group effects (p ≥ 0.304). Response and remission rates did not differ between conditions at follow-up (response MCT: 12.9%, BA: 13.3%, remission MCT: 9.7%, BA: 10.0%). The deterioration rate was lower in MCT than in BA (χ21 = 5.466, p = 0.019, NTT = 7.4). DISCUSSION: Both MCT and BA showed symptom reductions. Remission and response rates were lower than in previous studies, highlighting the need for further improvements in adapting/implementing treatments for severely affected patients with MDD.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder.

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial.

IMPORTANCE: Schema therapy (ST), delivered either in an individual or group format, has been compared with other active treatments for borderline personality disorder (BPD). To our knowledge, the 2 formats have not been compared with treatment as usual (TAU) or with each other. Such comparisons help determine best treatment practices. OBJECTIVE: To evaluate whether ST is more effectively delivered in a predominantly group or combined individual and group format and whether ST is more effective than optimal TAU for BPD. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter, 3-arm randomized clinical trial conducted at 15 sites in 5 countries (Australia, Germany, Greece, the Netherlands, and the UK), outpatients aged 18 to 65 years who had BPD were recruited between June 29, 2010, and May 18, 2016, to receive either predominantly group ST (PGST), combined individual and group ST (IGST), or optimal TAU. Data were analyzed from June 4, 2019, to December 29, 2021. INTERVENTIONS: At each site, cohorts of 16 to 18 participants were randomized 1:1 to PGST vs TAU or IGST vs TAU. Both ST formats were delivered over 2 years, with 2 sessions per week in year 1 and the frequency gradually decreasing during year 2. Assessments were collected by blinded assessors. MAIN OUTCOMES AND MEASURES: The primary outcome was the change in BPD severity over time, assessed with the Borderline Personality Disorder Severity Index (BPDSI) total score. Treatment retention was analyzed as a secondary outcome using generalized linear mixed model survival analysis. RESULTS: Of 495 participants (mean [SD] age, 33.6 [9.4] years; 426 [86.2%] female), 246 (49.7%) received TAU, 125 (25.2%) received PGST, and 124 (25.0%) received IGST (1 of whom later withdrew consent). PGST and IGST combined were superior to TAU with regard to reduced BPD severity (Cohen d, 0.73; 95% CI, 0.29-1.18; P < .001). For this outcome, IGST was superior to TAU (Cohen d, 1.14; 95% CI, 0.57-1.71; P < .001) and PGST (Cohen d, 0.84; 95% CI, 0.09-1.59; P = .03), whereas PGST did not differ significantly from TAU (Cohen d, 0.30; 95% CI, -0.29 to 0.89; P = .32). Treatment retention was greater in the IGST arm than in the PGST (1 year: 0.82 vs 0.72; 2 years: 0.74 vs. 0.62) and TAU (1 year: 0.82 vs 0.73; 2 years: 0.74 vs 0.64) arms, and there was no significant difference between the TAU and PGST arms (1 year: 0.73 vs 0.72; 2 years: 0.64 vs 0.62). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, IGST was more effective and had greater treatment retention compared with TAU and PGST. These findings suggest that IGST is the preferred ST format, with high retention and continuation of improvement in BPD severity after the completion of treatment. TRIAL REGISTRATION: trialregister.nl Identifier: NTR2392.

The societal cost of treatment-seeking patients with borderline personality disorder in Germany.

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

Does childhood emotional abuse moderate the effect of cognitive behavioral analysis system of psychotherapy versus meta-cognitive therapy in depression? A propensity score analysis on an observational study.

Background Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT) are effective for depression. CBASP might offer most benefit in patients reporting childhood emotional abuse (CEA). This needs to be confirmed in real-world settings and in comparisons with depression-specific psychotherapies. This study examines the moderating influence of CEA on the effectiveness of CBASP versus MCT. Methods In this observational study, we recruited patients treated with either CBASP or MCT in an intensive day treatment program for depression. CEA was assessed using the Childhood Trauma Questionnaire (CTQ). Patients reported symptoms weekly using the Quick Inventory of Depressive Symptoms (QIDS-SR). Mixed model analysis was run on the Intention to Treat dataset (ITT) using propensity matching to overcome baseline imbalances. Results A total of 141 patients were included in the analysis (MCT n = 78, CBASP n = 63). CEA moderated the treatment effect (time x CEA x treatment: ß = 0.03, SE = 0.01, p = 0.014). Post-hoc analyses revealed that CBASP was more effective than MCT in patients without CEA (time x treatment: ß = -0.01, SE = 0.007, p = .045). The difference between CBASP and MCT was not statistically significant for patients with CEA (ß = 0.015, SE = 0.008, p = .11). Limitations Because of non-random treatment allocation the differences between CBASP and MCT can be due to unobserved baseline imbalances. Conclusions Our findings suggest that in patients reporting CEA, CBASP might not offer additional benefits above other depression-specific psychotherapies. Public Health Significance Statements This study shows that, on average, individuals with depression benefit equally from CBASP and MCT under the conditions of routine practice. Yet, CBASP was more effective than MCT for those without childhood emotional abuse. If childhood emotional abuse was present, CBASP and MCT were equally effective.

Differential effect of childhood emotional abuse on present social support in borderline disorder and depression: a cross-sectional study.

Background: Perceived social support (PSS) is a crucial factor in physical and mental health. Previous studies found a negative association between childhood maltreatment (CM) and current PSS. Objective: In this paper, we investigate whether psychopathology moderates this association in a sample of patients with Depressive Disorder (DD) and Borderline Personality Disorder (BPD). Method: Sixty-nine patients with DD and 110 patients with BPD were recruited to inpatient/day clinic treatment programmes for either DD or BPD. All participants completed the Childhood Trauma Questionnaire (CTQ) and the Social Support Questionnaire (F-SozU). Our hypothesis was tested with a moderator analysis in a multiple linear regression model. Results: We found a significant interaction between diagnosis and CM for the CTQ total score and the emotional abuse subscale. Post hoc analyses revealed a significant negative correlation between CM and PSS only for patients suffering from BPD and not for patients with DD. Conclusion: Our results suggest that the negative association between CM and PSS might be more pronounced in certain patient groups, particularly patients with BPD.

Antecedentes: El apoyo social percibido (PSS en su sigla en inglés) es un factor crucial en la salud física y mental. Estudios previos encontraron una asociación negativa entre el maltrato infantil (MI) y el PSS actual.Objetivo: En este trabajo investigamos si la psicopatología modera esta asociación en una muestra de pacientes con trastorno depresivo (DD en su sigla en inglés) y trastorno límite de la personalidad (TLP).Método: Sesenta y nueve pacientes con DD y 110 pacientes con TLP fueron reclutados en programas de tratamiento clínico para pacientes de hospital diurno para DD o TLP. Todos los participantes completaron el cuestionario de trauma infantil (CTQ en su sigla en inglés) y el Cuestionario de apoyo social (F-SozU). Nuestra hipótesis fue probada con un análisis de moderador en un modelo de regresión lineal múltiple.Resultados: Encontramos una interacción significativa entre el diagnóstico y el MI para la puntuación total del CTQ y la subescala de abuso emocional. Los análisis post hoc revelaron una correlación negativa significativa entre MI y PSS solo para pacientes que padecían TLP y no para pacientes con DD.Conclusión: Nuestros resultados sugieren que la asociación negativa entre MI y PSS podría ser más pronunciada en ciertos grupos de pacientes, particularmente en pacientes con TLP.

How patients with borderline personality disorder experience the skill opposite action in the context of dialectical behavior therapy-A qualitative study.

Dialectical behavior therapy (DBT) is currently the most researched therapy method to treat borderline personality disorder (BPD). A major component of DBT is learning and practicing specific skills to regulate emotions. Qualitative studies found that patients perceived DBT skills as helpful in dealing with emotions. However, DBT consists of more than 60 different skills, and earlier qualitative studies had a broad focus. The present study explores patients' experience with a specific skill, opposite action (OA). The skill is one of the major DBT skills assumed to play an important role in symptom improvement. OA means deliberately performing a behavior that is opposite to the emotional urge to act and is intended to weaken the original emotion. Qualitative data from semistructured interviews with 23 patients diagnosed with BPD receiving DBT were analyzed following qualitative content analysis procedures. The participants generally had a good understanding of the skill, although it was often mixed with other skills of DBT. Performing OA was perceived as exhausting. Adverse effects of OA, intense emotions and high distress were reported as barriers to OA use. However, participants named several factors that helped them overcome these barriers, including their thoughts and actions, support from others, and treatment elements. Participants described positive effects of OA such as positive emotional changes and a decrease in problem behavior and more freedom in everyday life. The findings of the study provide valuable information to optimize the delivery of OA and DBT and can help to improve treatment outcome for patients with BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Investigating Care Dependency and Its Relation to Outcome (ICARE): Results From a Naturalistic Study of an Intensive Day Treatment Program for Depression.

Background: This study explores the association of experienced dependency in psychotherapy as measured with the CDQ (Care Dependency Questionnaire) and treatment outcome in depression. Furthermore, the course of care dependency and differences in the CDQ scores depending on the received type of treatment, MCT (metacognitive therapy), or CBASP (cognitive behavioral analysis system of psychotherapy), were investigated. Methods: The study follows a prospective, parallel group observational design. Patients suffering from depression received an 8-week intensive day clinic program, which was either CBASP or MCT. The treatment decision was made by clinicians based on the presented symptomatology and with regard to the patients' preferences. The patients reported depressive symptoms with the QIDS-SR16 (Quick Inventory of Depressive Symptomatology) and levels of experienced care dependency with the German version of the CDQ on a weekly basis. Mixed-model analyses were run to account for the repeated-measures design. Results: One hundred patients were included in the analyses. Results indicate that higher levels of care dependency might predict a less favorable outcome of depressive symptomatology. Levels of care dependency as well as depressive symptoms decreased significantly over the course of treatment. There was no significant between-group difference in care dependency between the two treatment groups. Conclusion: The results suggest that care dependency might be associated with a worse treatment outcome in depressed patients. In general, care dependency seems to be a dynamic construct, as it is changing over time, while the levels of care dependency seem to be independent from the received type of treatment. Future research should continue investigating the mechanisms of care dependency in a randomized controlled design. Clinical Trial Registration: https://www.drks.de/drks_web/, identifier: DRKS00023779.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial.

BACKGROUND: Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study's aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated. METHODS: The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains. DISCUSSION: This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome. TRIAL REGISTRATION: Netherlands Trial Register NL6965, registered 25/04/2018.

Change in Interpersonal and Metacognitive Skills During Treatment With Cognitive Behavioral Analysis System of Psychotherapy and Metacognitive Therapy: Results From an Observational Study.

Background: Interpersonal skills deficits and dysfunctional metacognitive beliefs have been implicated in the etiology and maintenance of depression. This study aimed to investigate the association between changes in these skills deficits and change in depressive symptoms over the course of treatment with Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT). Methods: In this prospective, parallel group observational study, data was collected at baseline and after 8 weeks of an intensive day clinic psychotherapy program. Based on a shared decision between patients and clinicians, patients received either CBASP or MCT. Ninety patients were included in the analyses (CBASP: age M = 38.7, 40.5% female, MCT: age M = 44.7, 43.3% female). Interpersonal deficits were assessed with the short-form of the Luebeck Questionnaire for Recording Preoperational Thinking (LQPT-SF) and the Impact Message Inventory (IMI-R). Metacognitive beliefs were assessed with the Metacognition Questionnaire-30 (MCQ-30). The Quick Inventory of Depressive Symptomatology (QIDS-SR16) was utilized to assess depressive symptoms. A regression analysis was conducted to assess variables associated with outcome. ANCOVAs were utilized to investigate whether improvement in skills deficits is dependent on type of treatment received. Results: Improvements in preoperational thinking and increases in friendly-dominant behavior were associated with change in depressive symptoms. There was no association between reductions in dysfunctional metacognitive beliefs and a decrease in depressive symptoms. While both treatment groups showed significant improvements in interpersonal and metacognitive skills, there was no significant between-group difference in the change scores for either of these skills. Conclusion: Our findings suggest that changes in interpersonal skills seem to be of particular relevance in the treatment of depression. These results have to be replicated in a randomized-controlled design before firm conclusions can be drawn.

Effectiveness and safety of the adjunctive use of an internet-based self-management intervention for borderline personality disorder in addition to care as usual: results from a randomised controlled trial.

IMPORTANCE: Borderline personality disorder (BPD) is a severe mental disorder that is often inadequately treated. OBJECTIVE: To determine if adding a self-management intervention to care as usual (CAU) is effective and safe. DESIGN: Randomised, controlled, rater-blind trial. Duration of treatment and assessments: 12 months. SETTING: Secondary care, recruited mainly via the internet. PARTICIPANTS: Patients with BPD and BPD Severity Index (BPDSI) of at least 15. INTERVENTIONS: CAU by treating psychiatrist and/or psychotherapist alone or adjunctive use of an internet-based self-management intervention that is based on schema therapy (priovi). MAIN OUTCOME MEASURE: Outcomes were assessed by trained raters. The primary outcome was change in BPDSI. The safety outcome was the number of serious adverse events (SAEs). The primary outcome time point was 12 months after randomisation. RESULTS: Of 383 participants assessed for eligibility, 204 were included (91.7% female, mean age: 32.4 years; 74% were in psychotherapy and 26% were in psychiatric treatment). The slope of BPDSI change did not differ significantly between groups from baseline to 12 months (F3,248= 1.857, p=0.14). At 12 months, the within-group effect sizes were d=1.38 (95% CI 1.07 to 1.68) for the intervention group and d=1.02 (95% CI 0.73 to 1.31) for the control group. The between-group effect size was d=0.27 (95% CI 0.00 to 0.55) in the intention-to-treat sample and d=0.39 (95% CI 0.09 to 0.68) for those who used the intervention for at least 3 hours (per-protocol sample). We found no significant differences in SAEs. CONCLUSIONS: We have not found a significant effect in favour of the intervention. This might be due to the unexpectedly large effect in the group receiving CAU by a psychiatrist and/or psychotherapist alone. TRIAL REGISTRATION: NCT03418142.

The mediating effect of difficulties in emotion regulation on the association between childhood maltreatment and borderline personality disorder.

Background: Childhood maltreatment and difficulties in emotion regulation are common in patients with Borderline Personality Disorder (BPD) and Depressive Disorders (DD). Objective: This study examines differences between patients with BPD and patients with DD, regarding childhood maltreatment and difficulties in emotion regulation as well as the mediating effect of different aspects of emotion regulation deficits on the association between childhood maltreatment and BPD-symptoms. Method: A total of 305 participants, 177 with BPD and 128 with DD completed an assessment including the Childhood Trauma Questionnaire (CTQ), the Emotion Regulation Scale (DERS), the Brief Symptom Inventory (BSI), and the Structured Clinical Interview for DSM-IV (SCID). Data was analyzed using multiple analyses of variances and mediation analyses. Results: Patients with BPD reported more childhood maltreatment and more difficulties in emotion regulation than patients with DD. When general symptom severity, age, and gender were included in the analysis as covariates only group differences regarding 'impulse control difficulties' (F(1,299) = 38.97, p < .001, ηp2 = .115), 'limited access to emotion regulation strategies' (F(1,299) = 4.66, p = .032, ηp2 = .015), and 'lack of emotional clarity' (F(1,299) = 9.38, p = .002, ηp2 = .030) remained statistically significant. A mediation analysis, including above-mentioned covariates, indicated an association between emotional abuse and BPD-symptoms, which was mediated by difficulties in emotion regulation (indirect effect B = .012, 95% CI [.001; .031], R2 = .429). Subscale analyses revealed 'impulse control difficulties' as the aspect of difficulties in emotion regulation that has the greatest impact on this association (B = .021, 95% CI [.003; .045]). Conclusions: Patients with BPD display more childhood maltreatment and difficulties in emotion regulation than patients with DD. Difficulties in emotion regulation, especially difficulties in impulse control, seem to play an important role in the association between childhood emotional abuse and BPD-symptoms.

Antecedentes: El maltrato infantil y las dificultades en la regulación emocional son frecuentesw en pacientes con trastorno límite de personalidad (TLP) y pacientes con trastornos depresivos (TD).Objetivo: Este estudio examina las diferencias entre pacientes con TLP y pacientes con TD, en cuanto al maltrato infantil y las dificultades en la regulación de las emociones, así como el efecto mediador de diferentes aspectos de los déficits en la regulación de las emociones sobre la asociación entre el maltrato infantil y los síntomas del TLP.Método: Un total de 305 participantes, 177 pacientes con TLP y 128 pacientes con TD completaron una evaluación que incluyó el Cuestionario de Trauma Infantil (CTQ), la Escala de Regulación de las Emociones (DERS), el Inventario Breve de Síntomas (BSI) y la Entrevista Clínica Estructurada para DSM-IV (SCID). Los datos se analizaron mediante múltiples análisis de variaciones y análisis de mediación.Resultados: Los pacientes con TLP informaron más maltrato infantil y más dificultades en la regulación de las emociones que los pacientes con TD. Cuando la gravedad de los síntomas generales, la edad y el sexo se incluyeron en el análisis como covariables, solo las diferencias de grupo con respecto a las 'dificultades de control de impulsos' (F (1.299) = 38,97, p <.001, ηp2 = .115), 'acceso limitado a estrategias de regulación de las emociones '(F (1,299) = 4.66, p = .032, ηp2 = .015) y' falta de claridad emocional '(F (1,299) = 9.38, p = .002, ηp2 = .030) permanecieron estadísticamente significativas. Un análisis de mediación, incluidas las covariables antes mencionadas, indicó una asociación entre el abuso emocional y los síntomas del TLP, que fue mediada por dificultades en la regulación de las emociones (efecto indirecto B = .012, IC del 95% [.001; .031], R2 =. 429). Los análisis de subescalas revelaron "dificultades de control de impulsos" como el aspecto de las dificultades en la regulación de las emociones que tiene el mayor impacto en esta asociación (B = .021, IC del 95% [.003; .045]).Conclusiones: Los pacientes con TLP presentan más maltrato infantil y dificultades en la regulación de las emociones que los pacientes con TD. Las dificultades en la regulación de las emociones, especialmente las dificultades en el control de los impulsos, parecen jugar un papel importante en la asociación entre el abuso emocional infantil y los síntomas del TLP.

Differential Effects of Comorbid Psychiatric Disorders on Treatment Outcome in Posttraumatic Stress Disorder from Childhood Trauma.

Patients with posttraumatic stress disorder (PTSD) frequently have comorbid diagnoses such as major depressive disorder (MDD) and anxiety disorders (AD). Studies into the impact of these comorbidities on the outcome of PTSD treatment have yielded mixed results. The different treatments investigated in these studies might explain the varied outcome. The purpose of this study was to examine the impact of these comorbidities on the outcome of two specific PTSD treatments. MDD and AD were analyzed as predictors and moderators in a trial comparing 12 sessions of either eye movement desensitization and reprocessing (EMDR) or imagery rescripting (IR) in 155 adult patients with PTSD from childhood trauma. The primary outcome was reduction of PTSD symptoms (clinician-administered PTSD Scale for DSM-5, CAPS-5) assessed at eight-week follow-up and a secondary outcome was self-report PTSD symptoms (Impact of Event Scale, IES-R). MDD was not a predictor of treatment outcome but did have a significant moderator effect. Patients with MDD showed a better outcome if they were treated with IR, whereas patients without MDD improved more in the EMDR condition. No impact of AD emerged. It seems essential to consider comorbid MDD when planning PTSD treatment to improve treatment outcomes. More research is needed to replicate our findings and focus on different kinds of PTSD treatments and other comorbidities.

How do patients with borderline personality disorder experience Distress Tolerance Skills in the context of dialectical behavioral therapy?-A qualitative study.

Distress Tolerance Skills (DTS) are an important component of Dialectical Behavioral Therapy (DBT), a therapy method frequently used for treating patients with Borderline Personality Disorder (BPD). However, little is known about how DTS-training is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving DTS-training. Qualitative data were collected through semi-structured interviews with 24 individuals (87.5% females) with a primary diagnosis of BPD who received DTS-training in the context of 18 months of DBT treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of DTS including an immediate reduction of tension. Patients perceived DTS as a tool to cope with difficult interpersonal situations and emergencies and stated that this helped them to feel stable, safe and self-confident. Patients reported difficulties during the initial engagement, the learning process and the application of DTS as well as various facilitating factors. Implications of the findings for further research and for optimizing DTS-training in clinical practice are discussed.

Patient and Therapist Perspectives on Treatment for Adults with PTSD from Childhood Trauma.

This study aimed to explore patients' and therapists' experiences with trauma-focused treatments in patients with posttraumatic stress disorder from childhood trauma (Ch-PTSD). Semi-structured interviews were conducted with patients (n = 44) and therapists (n = 16) from an international multicentre randomised clinical trial comparing two trauma-focused treatments (IREM), imagery rescripting and eye movement and desensitisation (EMDR). Thematic analysis was used to identify key themes within the data. Patients and therapists commented about the process of therapy. The themes that emerged from these comments included the importance of the patients' willingness to engage and commit to the treatment process; the importance and difficulty of the trauma work, observations of how the trauma focused therapy produced changes in insight, and sense of self and empowerment for the future. In addition, therapists made suggestions for optimising the therapist role in the trauma-focused treatment. This included the importance of having confidence in their own ability, confronting their own and their client's avoidance and the necessity and difficulties of adhering to the treatment protocols. These reported experiences add further support to the idea that trauma-focused treatments, without a stabilisation phase, can be tolerated and deepens our understanding of how to make this palatable for individuals with Ch-PTSD.

Experiences of Patients With Borderline Personality Disorder With Imagery Rescripting in the Context of Schema Therapy-A Qualitative Study.

Imagery Rescripting (IR) is a therapeutic technique that is used in a wide spectrum of therapeutic methods for various mental disorders. As an important component of Schema Therapy (ST), IR is frequently used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how IR is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving IR. Qualitative data were collected through semi-structured interviews with 21 individuals (86% females) with a primary diagnosis of BPD who received IR within their ST treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of IR including initial high emotionality and exhaustion. Long-term effects included a better understanding of schemas and an improvement regarding emotion regulation and interpersonal relationships. Participants reported factors hindering the successful implementation of IR, such as external noise, stress, and a fast pace during IR. Facilitating factors included adequate time for debriefing, a transparent structure, and preparation of IR as well as the therapist providing safety. Implications of the findings for optimizing IR in clinical practice are discussed.