An experimental examination of neurostimulation and cognitive restructuring as potential components for Misophonia interventions.

Misophonia is a disorder of decreased tolerance to certain aversive, repetitive common sounds, or to stimuli associated with these sounds. Two matched groups of adults (29 participants with misophonia and 30 clinical controls with high emotion dysregulation) received inhibitory neurostimulation (1 Hz) over a personalized medial prefrontal cortex (mPFC) target functionally connected to the left insula; excitatory neurostimulation (10 Hz) over a personalized dorsolateral PFC (dlPFC) target; and sham stimulation over either target. Stimulations were applied while participants were either listening or cognitively downregulating emotions associated with personalized aversive, misophonic, or neutral sounds. Subjective units of distress (SUDS) and psychophysiological measurements (e.g., skin conductance response [SCR] and level [SCL]) were collected. Compared to controls, participants with misophonia reported higher distress (∆SUDS = 1.91-1.93, ps < 0.001) when listening to and when downregulating misophonic distress. Both types of neurostimulation reduced distress significantly more than sham, with excitatory rTMS providing the most benefit (Cohen's dSUDS = 0.53; dSCL = 0.14). Excitatory rTMS also enhanced the regulation of emotions associated with misophonic sounds in both groups when measured by SUDS (dcontrol = 1.28; dMisophonia = 0.94), and in the misophonia group alone when measured with SCL (d = 0.20). Both types of neurostimulation were well tolerated. Engaging in cognitive restructuring enhanced with high-frequency neurostimulation led to the lowest misophonic distress, highlighting the best path forward for misophonia interventions.

Network-level dynamics underlying a combined rTMS and psychotherapy treatment for major depressive disorder: An exploratory network analysis

Background: Despite the growing use of repetitive transcranial magnetic stimulation (rTMS) as a treatment for depression, there is a limited understanding of the mechanisms of action and how potential treatment-related brain changes help to characterize treatment response. To address this gap in understanding we investigated the effects of an approach combining rTMS with simultaneous psychotherapy on global functional connectivity. Method: We compared task-related functional connectomes based on an idiographic goal priming task tied to emotional regulation acquired before and after simultaneous rTMS/psychotherapy treatment for patients with major depressive disorders and compared these changes to normative connectivity patterns from a set of healthy volunteers (HV) performing the same task. Results: At baseline, compared to HVs, patients demonstrated hyperconnectivity of the DMN, cerebellum and limbic system, and hypoconnectivity of the fronto-parietal dorsal-attention network and visual cortex. Simultaneous rTMS/psychotherapy helped to normalize these differences, which were reduced after treatment. This finding suggests that the rTMS/therapy treatment regularizes connectivity patterns in both hyperactive and hypoactive brain networks. Conclusions: These results help to link treatment to a comprehensive model of the neurocircuitry underlying depression and pave the way for future studies using network-guided principles to significantly improve rTMS efficacy for depression. (AU)

Mechanisms of change in treatments for transdiagnostic emotion dysregulation: The roles of skills use, perceived control and mindfulness.

Emotion dysregulation (ED) is a key target for change among empirically supported treatments for emotional disorders, including dialectical behaviour therapy skills training (DBT-ST), yet how treatments improve ED is poorly understood. Using data from a randomised trial of DBT-ST versus supportive group therapy for transdiagnostic ED, we tested whether three mechanistic variables-behavioural skills use, mindfulness, and perceived control-explain variability in ED within people over time. We additionally explored the mediating roles of these variables between conditions. Adults with transdiagnostic ED (N = 44) participated in weekly groups for 4 months, with assessments at pre-, mid- and post-treatment and at 2-month follow-up. As hypothesised, multilevel models disaggregating within- and between-person effects indicated that skills use, mindfulness, and perceived control each had significant total and unique within-person associations with ED at concurrent time points, net the effect of time. Unexpectedly, these within-person relations were not significant for mechanistic variables predicting ED 2 months later. Further, unique between-person variability in skills use, mindfulness, and perceived control did not significantly mediate the relationship between condition and ED improvements. The present study is an important step in clarifying ED mechanisms of change, both within and between persons.

Network-level dynamics underlying a combined rTMS and psychotherapy treatment for major depressive disorder: An exploratory network analysis.

Background: Despite the growing use of repetitive transcranial magnetic stimulation (rTMS) as a treatment for depression, there is a limited understanding of the mechanisms of action and how potential treatment-related brain changes help to characterize treatment response. To address this gap in understanding we investigated the effects of an approach combining rTMS with simultaneous psychotherapy on global functional connectivity. Method: We compared task-related functional connectomes based on an idiographic goal priming task tied to emotional regulation acquired before and after simultaneous rTMS/psychotherapy treatment for patients with major depressive disorders and compared these changes to normative connectivity patterns from a set of healthy volunteers (HV) performing the same task. Results: At baseline, compared to HVs, patients demonstrated hyperconnectivity of the DMN, cerebellum and limbic system, and hypoconnectivity of the fronto-parietal dorsal-attention network and visual cortex. Simultaneous rTMS/psychotherapy helped to normalize these differences, which were reduced after treatment. This finding suggests that the rTMS/therapy treatment regularizes connectivity patterns in both hyperactive and hypoactive brain networks. Conclusions: These results help to link treatment to a comprehensive model of the neurocircuitry underlying depression and pave the way for future studies using network-guided principles to significantly improve rTMS efficacy for depression.

The neurobiology of misophonia and implications for novel, neuroscience-driven interventions.

Decreased tolerance in response to specific every-day sounds (misophonia) is a serious, debilitating disorder that is gaining rapid recognition within the mental health community. Emerging research findings suggest that misophonia may have a unique neural signature. Specifically, when examining responses to misophonic trigger sounds, differences emerge at a physiological and neural level from potentially overlapping psychopathologies. While these findings are preliminary and in need of replication, they support the hypothesis that misophonia is a unique disorder. In this theoretical paper, we begin by reviewing the candidate networks that may be at play in this complex disorder (e.g., regulatory, sensory, and auditory). We then summarize current neuroimaging findings in misophonia and present areas of overlap and divergence from other mental health disorders that are hypothesized to co-occur with misophonia (e.g., obsessive compulsive disorder). Future studies needed to further our understanding of the neuroscience of misophonia will also be discussed. Next, we introduce the potential of neurostimulation as a tool to treat neural dysfunction in misophonia. We describe how neurostimulation research has led to novel interventions in psychiatric disorders, targeting regions that may also be relevant to misophonia. The paper is concluded by presenting several options for how neurostimulation interventions for misophonia could be crafted.

Enhancing cognitive restructuring with concurrent fMRI-guided neurostimulation for emotional dysregulation-A randomized controlled trial.

BACKGROUND: Transdiagnostic clinical emotional dysregulation is a key component of many mental health disorders and offers an avenue to address multiple disorders with one transdiagnostic treatment. In the current study, we pilot an intervention that combines a one-time teaching and practice of cognitive restructuring (CR) with repetitive transcranial magnetic stimulation (rTMS), targeted based on functional magnetic resonance imaging (fMRI). METHODS: Thirty-seven clinical adults who self-reported high emotional dysregulation were enrolled in this randomized, double-blind, placebo-controlled trial. fMRI was collected as participants were reminded of lifetime stressors and asked to downregulate their distress using CR tactics. fMRI BOLD data were analyzed to identify the cluster of voxels within the left dorsolateral prefrontal cortex (dlPFC) with the highest activation when participants attempted to downregulate, versus passively remember, distressing memories. Participants underwent active or sham rTMS (10 Hz) over the left dlPFC target while practicing CR following emotional induction using recent autobiographical stressors. RESULTS: Receiving active versus sham rTMS led to significantly higher high frequency heart rate variability during regulation, lower regulation duration during the intervention, and higher likelihood to use CR during the week following the intervention. There were no differences between conditions when administering neurostimulation alone without the CR skill and compared to sham. Participants in the sham versus active condition experienced less distress the week after the intervention. There were no differences between conditions at the one-month follow up. CONCLUSION: This study demonstrated that combining active rTMS with emotion regulation training for one session significantly enhances emotion regulation and augments the impact of training for as long as a week. These findings are a promising step towards a combined intervention for transdiagnostic emotion dysregulation.

Multilevel associations of daily skill use and effectiveness with anxiety, depression, and stress in a transdiagnostic sample undergoing dialectical behavior therapy skills training.

Dialectical Behavior Therapy (DBT) is effective at treating disorders of emotion dysregulation. However, it is unclear which mechanisms contribute to these effects. The aim of this study was to characterize the within-person associations of two theoretically relevant mechanisims of change, skill use and skill effectiveness, with anxiety, stress, and depression. Participants (n = 19, Mage = 31.8, 68% female) with a primary anxiety or depressive disorder completed daily reports (N = 1344) of DBT skill use, perceived effectiveness, anxiety, stress, and depression during a 16-session DBT skills training group. DBT skill use increased across treatment, p < .01, but effectiveness did not, p = .64. Within persons, participants used more skills on days with greater stress and anxiety, p < .01, which predicted next-day decreases in stress and anxiety, p = .03. On days when participants reported higher effectiveness, they used more skills than their personal average when experiencing more intense negative affect, p < .01. These results suggest using more skills, especially when used more effectively, is a mechanism by which DBT skills groups address emotional dysfunction for those with transdiagnostic emotional disorders.

Enhancing Cognitive Restructuring with Concurrent Repetitive Transcranial Magnetic Stimulation: A Transdiagnostic Randomized Controlled Trial.

INTRODUCTION: Emotional dysregulation constitutes a serious public health problem in need of novel transdiagnostic treatments. OBJECTIVE: To this aim, we developed and tested a one-time intervention that integrates behavioral skills training with concurrent repetitive transcranial magnetic stimulation (rTMS). METHODS: Forty-six adults who met criteria for at least one DSM-5 disorder and self-reported low use of cognitive restructuring (CR) were enrolled in a randomized, double-blind, sham-controlled trial that used a between-subjects design. Participants were taught CR and underwent active rTMS applied at 10 Hz over the right (n = 17) or left (n = 14) dorsolateral prefrontal cortex (dlPFC) or sham rTMS (n = 15) while practicing reframing and emotional distancing in response to autobiographical stressors. RESULTS: Those who received active left or active right as opposed to sham rTMS exhibited enhanced regulation (ds = 0.21-0.62) as measured by psychophysiological indices during the intervention (higher high-frequency heart rate variability, lower regulation duration). Those who received active rTMS over the left dlPFC also self-reported reduced distress throughout the intervention (d = 0.30), higher likelihood to use CR, and lower daily distress during the week following the intervention. The procedures were acceptable and feasible with few side effects. CONCLUSIONS: These findings show that engaging frontal circuits simultaneously with cognitive skills training and rTMS may be clinically feasible, well-tolerated and may show promise for the treatment of transdiagnostic emotional dysregulation. Larger follow-up studies are needed to confirm the efficacy of this novel therapeutic approach.

Examining the Role of Lateral Parietal Cortex in Emotional Distancing Using TMS.

We recently proposed a neurocognitive model of distancing-an emotion regulation tactic-with a focus on the lateral parietal cortex. Although this brain area has been implicated in both cognitive control and self-projection processes during distancing, fMRI work suggests that these processes may be dissociable here. This preregistered (NCT03698591) study tested the contribution of left temporoparietal junction (TPJ) to distancing using repetitive transcranial magnetic stimulation. We hypothesized that inhibiting left TPJ would decrease the efficiency of distancing but not distraction, another regulation tactic with similar cognitive control requirements, thus implicating this region in the self-projection processes unique to distancing. Active and sham continuous theta burst stimulation (cTBS) were applied to 30 healthy adults in a single-session crossover design. Tactic efficiency was measured using online reports of valence and effort. The stimulation target was established from the group TPJ fMRI activation peak in an independent sample using the same distancing task, and anatomical MRI scans were used for individual targeting. Analyses employed both repeated-measures ANOVA and analytic procedures tailored to crossover designs. Irrespective of cTBS, distancing led to greater decreases in negative valence over time relative to distraction, and distancing effort decreased over time while distraction effort remained stable. Exploratory analyses also revealed that active cTBS made distancing more effortful, but not distraction. Thus, left TPJ seems to support self-projection processes in distancing, and these processes may be facilitated by repeated use. These findings help to clarify the role of lateral parietal cortex in distancing and inform applications of distancing and distraction.

On the Concurrent Use of Self-System Therapy and Functional Magnetic Resonance Imaging-Guided Transcranial Magnetic Stimulation as Treatment for Depression.

OBJECTIVES: Despite the growing use of repetitive transcranial magnetic stimulation (rTMS) as a treatment for unipolar depression, its typical effect sizes have been modest, and methodological and conceptual challenges remain regarding how to optimize its efficacy. Linking rTMS to a model of the neurocircuitry underlying depression and applying such a model to personalize the site of stimulation may improve the efficacy of rTMS. Recent developments in the psychology and neurobiology of self-regulation offer a conceptual framework for identifying mechanisms of action in rTMS for depression, as well as for developing guidelines for individualized rTMS treatment. We applied this framework to develop a multimodal treatment for depression by pairing self-system therapy (SST) with simultaneously administered rTMS delivered to an individually targeted region of dorsolateral prefrontal cortex identified via functional magnetic resonance imaging (fMRI). METHODS: In this proof-of-concept study, we examined the acceptability, feasibility, and preliminary efficacy of combining individually fMRI-targeted rTMS with SST. Using the format of a cognitive paired associative stimulation paradigm, the treatment was administered to 5 adults with unipolar depression in an open-label trial. RESULTS: The rTMS/SST combination was well tolerated, feasible, and acceptable. Preliminary evidence of efficacy also was promising. We hypothesized that both treatment modalities were targeting the same neural circuitry through cognitive paired associative stimulation, and observed changes in task-based fMRI were consistent with our model. These neural changes were directly related to improvements in depression severity. CONCLUSIONS: The new combination treatment represents a promising exemplar for theory-based, individually targeted, multimodal intervention in mood disorders.

Changes in Problematic Anger, Shame, and Disgust in Anxious and Depressed Adults Undergoing Treatment for Emotion Dysregulation.

Emotion dysregulation, the pervasive difficulty managing negative emotions, is a core problem across mood and anxiety disorders. Anger, shame, and disgust are particularly problematic emotions, impacting both disorder severity and treatment outcome. We previously found that a 16-week dialectical behavior therapy skills training group (DBT-ST) was superior to an activities-based support group (ASG) in decreasing emotion dysregulation in 44 adults with high emotion dysregulation who met diagnostic criteria for an anxiety or depressive disorder. We presently examine these participants' changes in anger, shame, disgust, and distress using self-reports collected over 6 months during and after treatment. Hierarchical linear modeling analyses show that DBT-ST was superior to ASG in decreasing anger suppression (d = 0.93) and distress (d = 1.04). Both conditions significantly reduced shame, disgust propensity, and disgust sensitivity, but neither was superior for these outcomes. The treatments did not significantly reduce anger expression. Mediation analyses suggest that condition indirectly influenced 4-month anger suppression, shame, and distress through its effect on 2-month emotion dysregulation. These findings suggest that DBT-ST is efficacious for certain problematic emotions and distress in depressed and anxious adults and that common factors may account for some, but not all, of its benefits.

Suicidal Behavior and Problems with Emotion Regulation.

We examined in two independent samples whether: (1) difficulties with emotion regulation predict suicide ideation and (2) depressed adults with a history of attempting suicide report and exhibit more emotion dysregulation compared to healthy and depressed controls. Difficulties with emotional clarity and relationship status were significant predictors of suicide ideation (Study 1). In Study 2, when compared to controls, depressed attempters reported significantly more difficulties with emotional clarity and emotional impulsivity. Attempters had significantly more difficulty than controls returning to heart rate baseline following a stressful task. Problems with emotions are therefore differentially connected to suicidal behaviors.

Challenging assumptions from emotion dysregulation psychological treatments.

BACKGROUND: Contemporary treatments assume that the inability to downregulate negative emotional arousal is a key problem in the development and maintenance of psychopathology and that lack of effective regulation efforts and a preference to use maladaptive regulation strategies is a primary mechanism. Though ubiquitous, there is limited empirical evidence to support this assumption. Therefore, the aim of the current study was to examine whether self-reported emotion dysregulation equated to difficulties reducing emotional arousal during a behavioral task and to primary use of maladaptive strategies to manage negative emotions. METHODS: 44 anxious and depressed adults with high emotion dysregulation induced negative distress using autobiographic memory recall. After induction, participants were instructed to downregulate but were not provided any specific instructions in strategies to use. Self-reported emotional arousal was assessed before and after induction and after regulation. Qualitative descriptions of regulation efforts were collected and codedinto effective and maladaptive strategies. RESULTS: The task was successful in inducing emotional arousal and participants were successful in their efforts to down regulate negative emotions. Additionally, effective regulation strategies were used more frequently than maladaptive strategies. LIMITATIONS: Data collected was exclusively self-report and the sample size was small. CONCLUSION: Adults who report high emotion dysregulation may still have effective emotion regulation strategies in their behavioral repertoire and are more likely to engage in these effective strategies when given an unspecific prompt to regulate negative emotional arousal. Despite reporting problems with emotion regulation, adults with anxiety and depression can successfully downregulate distress when prompted to do so.

Dialectical behavior therapy skills use and emotion dysregulation in personality disorders and psychopathy: a community self-report study.

BACKGROUND: Emotion dysregulation is a critical transdiagnostic mental health problem that needs to be further examined in personality disorders (PDs). The current study examined dialectical behavior therapy (DBT) skills use, emotion dysregulation, and dysfunctional coping among adults who endorsed symptoms of cluster B PDs and psychopathy. We hypothesized that skills taught in DBT and emotion dysregulation are useful for adults with PDs other than borderline personality disorder (BPD). METHODS: Using a self-report questionnaire, we examined these constructs in three groups of community adults: those who reported symptoms consistent with borderline personality disorder (BPD; N = 29), those who reported symptoms consistent with any other cluster B PD (N = 22), and those with no reported cluster B PD symptoms (N = 77) as measured by the Personality Diagnostic Questionnaire-4 + . RESULTS: Both PD groups reported higher emotion dysregulation and dysfunctional coping when compared to the no PD group. Only the BPD group had significantly lower DBT skills use. DBT skills use was found to be a significant predictor of cluster B psychopathology but only before accounting for emotion dysregulation. When added to the regression model, emotion dysregulation was found to be a significant predictor of cluster B psychopathology but DBT skills use no longer had a significant effect. Across all groups, DBT skills use deficits and maladaptive coping, but not emotion dysregulation, predicted different facets of psychopathy. CONCLUSION: Emotion dysregulation and use of maladaptive coping are problems in cluster B PDs, outside of BPD, but not in psychopathy. Inability to use DBT skills may be unique to BPD. Because this study relied exclusively on self-report, this data is preliminary and warrants further investigation.

Psychotherapeutic Treatment of Bipolar Depression.

The gold standard for treating bipolar depression is based on the combination of mood stabilizers and psychotherapy. Therefore, the authors present evidence-based models and promising approaches for psychotherapy for bipolar depression. Cognitive-behavioral therapy, family focused therapy, interpersonal and social rhythm therapy, mindfulness-based cognitive therapy, and dialectical behavior therapy are discussed. Behavioral activation, the cognitive behavioral analysis system of psychotherapy, and the unified protocol as promising future directions are presented. This review informs medical providers of the most appropriate referral guidelines for psychotherapy for bipolar depression. The authors conclude with a decision tree delineating optimal referrals to each psychotherapy approach.

Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis.

IMPORTANCE: Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes. OBJECTIVE: To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy. DESIGN, SETTING, AND PARTICIPANTS: We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I. INTERVENTIONS: The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol. MAIN OUTCOMES AND MEASURES: Frequency and severity of suicide attempts and NSSI episodes. RESULTS: All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]). CONCLUSIONS AND RELEVANCE: A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00183651.

Identity disturbance and problems with emotion regulation are related constructs across diagnoses.

OBJECTIVE: This study examined the relation between identity disturbance and emotion dysregulation in a cross-diagnostic sample. We assessed whether these constructs are related and relevant beyond borderline personality disorder (BPD). METHOD: We recruited 127 participants who completed measures assessing identity disturbance, emotion dysregulation, anxiety, and depression. The sample included primarily depressed adults meeting criteria for multiple diagnoses as well as psychiatrically healthy participants. RESULTS: Identity disturbance was significantly higher among psychiatric participants with and without BPD compared to healthy controls. Emotion dysregulation was a significant predictor of identity disturbance, even when controlling for BPD diagnosis, depression, and anxiety. In particular, clarity in emotional situations and problems using emotion regulation strategies were most closely related to identity disturbance. CONCLUSION: The results of this study suggest that future research should examine identity disturbance and its relation with emotion regulation transdiagnostically.

Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial.

Difficulties with emotions are common across mood and anxiety disorders. Dialectical behavior therapy skills training (DBT-ST) reduces emotion dysregulation in borderline personality disorder (BPD). Preliminary evidence suggests that use of DBT skills mediates changes seen in BPD treatments. Therefore, we assessed DBT-ST as a stand-alone, transdiagnostic treatment for emotion dysregulation and DBT skills use as a mediator of outcome. Forty-four anxious and/or depressed, non-BPD adults with high emotion dysregulation were randomized to 16 weeks of either DBT-ST or an activities-based support group (ASG). Participants completed measures of emotion dysregulation, DBT skills use, and psychopathology every 2 months through 2 months posttreatment. Longitudinal analyses indicated that DBT-ST was superior to ASG in decreasing emotion dysregulation (d = 1.86), increasing skills use (d = 1.02), and decreasing anxiety (d = 1.37) but not depression (d = 0.73). Skills use mediated these differential changes. Participants found DBT-ST acceptable. Thirty-two percent of DBT-ST and 59% of ASG participants dropped treatment. Fifty-nine percent of DBT-ST and 50% of ASG participants complied with the research protocol of avoiding ancillary psychotherapy and/or medication changes. In summary, DBT-ST is a promising treatment for emotion dysregulation for depressed and anxious transdiagnostic adults, although more assessment of feasibility is needed.

Impact of dialectical behavior therapy versus community treatment by experts on emotional experience, expression, and acceptance in borderline personality disorder.

Evidence suggests that heightened negative affectivity is a prominent feature of Borderline Personality Disorder (BPD) that often leads to maladaptive behaviors. Nevertheless, there is little research examining treatment effects on the experience and expression of specific negative emotions. Dialectical Behavior Therapy (DBT) is an effective treatment for BPD, hypothesized to reduce negative affectivity (Linehan, 1993a). The present study analyzes secondary data from a randomized controlled trial with the aim to assess the unique effectiveness of DBT when compared to Community Treatment by Experts (CTBE) in changing the experience, expression, and acceptance of negative emotions. Suicidal and/or self-injuring women with BPD (n = 101) were randomly assigned to DBT or CTBE for one year of treatment and one year of follow-up. Several indices of emotional experience and expression were assessed. Results indicate that DBT decreased experiential avoidance and expressed anger significantly more than CTBE. No differences between DBT and CTBE were found in improving guilt, shame, anxiety, or anger suppression, trait, and control. These results suggest that DBT has unique effects on improving the expression of anger and experiential avoidance, whereas changes in the experience of specific negative emotions may be accounted for by general factors associated with expert therapy. Implications of the findings are discussed.

Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder.

A central component of Dialectical Behavior Therapy (DBT) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder (BPD) replace maladaptive behaviors with skillful behavior. Although existing evidence indirectly supports this proposed mechanism of action, no study to date has directly tested it. Therefore, we examined the skills use of 108 women with BPD participating in one of three randomized control trials throughout one year of treatment and four months of follow-up. Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started, participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment. Significant mediation effects also indicated that DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time. DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time. Anger suppression and expression were not mediated. This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior, depression, and anger control.