Predictors and moderators of recurring self-harm in adolescents participating in a comparative treatment trial of psychological interventions.

BACKGROUND: In primary analyses, dialectical behavior therapy (DBT) was associated with greater reduction in self-harm during treatment than individual/group supportive therapy (IGST). The objective of this paper was to examine predictors and moderators of treatment outcomes for suicidal adolescents who participated in a randomized controlled trial evaluating DBT and IGST. METHODS: Adolescents (N = 173) were included in the intent-to-treat sample and randomized to receive 6 months of DBT or IGST. Potential baseline predictors and moderators were identified within four categories: demographics, severity markers, parental psychopathology, and psychosocial variables. Primary outcomes were suicide attempts (SA) and nonsuicidal self-injury evaluated at baseline, midtreatment (3 months), and end of treatment (6 months) via the Suicide Attempt and Self-Injury Interview (Psychological Assessment, 18, 2006, 303). For each moderator or predictor, a generalized linear mixed model was conducted to examine main and interactive effects of treatment and the candidate variable on outcomes. RESULTS: Adolescents with higher family conflict, more extensive self-harm histories, and more externalizing problems produced on average more reduction on SH frequency from baseline to post-treatment. Adolescents meeting BPD diagnosis were more likely to have high SH frequency at post-treatment. Analyses indicated significant moderation effects for emotion dysregulation on NSSI and SH. DBT was associated with better rates of improvement compared to IGST for adolescents with higher baseline emotion dysregulation and those whose parents reported greater psychopathology and emotion dysregulation. A significant moderation effect for ethnicity on SA over the treatment period was observed, where DBT produced better rate of improvement compared to IGST for Hispanic/Latino individuals. CONCLUSIONS: These findings may help to inform salient treatment targets and guide treatment planning. Adolescents that have high levels of family conflict, externalizing problems, and increased level of severity markers demonstrated the most change in self-harm behaviors over the course of treatment and benefitted from both treatment interventions. Those with higher levels of emotion dysregulation and parent psychopathology may benefit more from the DBT.

Predictors of Adoption and Reach Following Dialectical Behavior Therapy Intensive Training™.

Dialectical behavior therapy (DBT) is an evidence-based treatment for borderline personality disorder. The DBT Intensive Training™ is widely used to train community clinicians to deliver DBT, but little is known about its effectiveness. This study prospectively evaluated predictors of adoption and reach of DBT among 52 community teams (212 clinicians) after DBT Intensive Training™. Pre-post training questionnaires were completed by trainees and a follow-up survey by team leaders approximately 8 months later. Overall, 75% of teams adopted all DBT modes and delivered DBT to an average of 118 clients. Lower training and program needs, fewer bachelor's-level clinicians, and greater prior DBT experience predicted adoption of more DBT modes. More prior DBT experience, smaller team size, more negative team functioning, and staff with lower job satisfaction, growth, efficacy, and influence predicted greater DBT reach. DBT Intensive Training™ appears effective in promoting DBT adoption and reach in routine clinical practice settings.

Evaluating a Multimedia Tool for Suicide Risk Assessment and Management: The Linehan Suicide Safety Net.

OBJECTIVE: The present study examined the usability and effectiveness of the Linehan Suicide Safety Net (LSSN), a web-based, multimedia tool designed to support clinicians working with individuals who are suicidal. The core feature of LSSN is the Linehan Risk Assessment and Management Protocol (LRAMP), an empirically derived protocol that provides a structured checklist for assessing, managing, and documenting suicide risk. METHOD: Mental health professionals (N = 44) completed assessments at baseline and monthly during a 3-month evaluation period. RESULTS: The LSSN was rated as acceptable and highly usable. Use of the LSSN was associated with a significant increase in confidence in conducting suicide risk assessment and management and a decrease in concerns related to treating suicidal clients. CONCLUSION: The LSSN appears to be a promising tool for clinicians working with suicidal clients.

Development and Initial Evaluation of the Psychometric Properties of the Dialectical Behavior Therapy Barriers to Implementation Scale (BTI-S).

OBJECTIVE: We examined the psychometric properties of the Dialectical Behavior Therapy (DBT) Barriers to Implementation Scale (BTI-S). METHOD: Participants were clinicians completing a bipartite training, separated by 6 months of self-study, to implement DBT. Exploratory factor analysis was conducted with data collected from the initial training period (N = 790), while confirmatory factor analysis was based on data from the final training period (N = 660). RESULTS: The final model included 26 items and 4 factors with overall acceptable fit, χ2 (293, N = 660) = 460.989, p < .001, comparative fit index = .909, Tucker-Lewis index = .899, root mean square root mean square error of approximation (90% confidence interval) = .015. The internal reliability of the scores was low (range = .56 to .72). CONCLUSION: The final model fits reasonably well and measures four domains considered important for implementation of DBT. However, the low reliability of the scores indicates that the BTI-S would be improved with further development.

Adapting dialectical behavior therapy for outpatient adult anorexia nervosa--a pilot study.

OBJECTIVE: Anorexia Nervosa (AN) is associated with excessive self-control. This iterative case series describes the augmentation of Dialectical Behavior Therapy (DBT) for outpatient adult AN with skills addressing emotional and behavioral overcontrol. An overly controlled style is theorized to develop from the transaction between an individual with heightened threat sensitivity and reduced reward sensitivity, interacting with an environment reinforcing overcontrol and punishing imperfection. METHOD: Case Series 1 utilized standard DBT, resulting in retention of 5/6 patients and a body mass index (BMI) effect size increase of d = -0.5 from pre- to post-treatment. Case series 2, using standard DBT augmented with skills addressing overcontrol, resulted in retention of 8/9 patients with an effect size increase in BMI at post-treatment that was maintained at 6- and 12-months follow-up (d = -1.12, d = -0.87, and d = -1.12). DISCUSSION: Findings suggest that skills training targeting rigidity and increasing openness and social connectedness warrant further study of this model and treatment for AN.

The Use of Dialectical Behavior Therapy and Prolonged Exposure to Treat Comorbid Dissociation and Self-Harm: The Case of a Client With Borderline Personality Disorder and Posttraumatic Stress Disorder.

There is a high rate of comorbidity between borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD; Pagura et al., 2010). Preliminary studies have evaluated the treatment of PTSD in a BPD population and found positive outcomes for the integration of dialectical behavior therapy (DBT) and prolonged exposure (PE). This case study illustrates the implementation of a PE protocol into standard DBT treatment, specifically focusing on the management of self-harm and severe dissociation for a client with co-occurring PTSD and BPD. The client entered into treatment with severe and persistent dissociation and a recent history of self-harm, and the case includes consideration of two separate pauses in PTSD treatment related to elevated dissociation and self-harm behaviors. The client successfully completed the DBT PE protocol and results indicate significant improvements in PTSD symptoms as well as outcomes related to self-harm and dissociation. These findings demonstrate the efficacy of combining DBT with PE for clients with comorbid BPD and PTSD and exemplify how complex clients with BPD who present with severe dissociation and self-harm behavior can safely and successfully receive treatment for PTSD.

The Course and Evolution of Dialectical Behavior Therapy.

Dialectical behavior therapy was originally developed from early efforts to apply standard behavior therapy to treat individuals who were highly suicidal. Its development was a trial and error effort driven primarily from clinical experience. Dialectical behavior therapy is a modular and hierarchical treatment consisting of a combination of individual psychotherapy, group skills, training, telephone coaching, and a therapist consultation team. The inherent modularity and hierarchical structure of DBT has allowed for relative ease in adapting and applying the treatment to other populations and settings. New skills have been developed and/or modified due to clinical need and/or advancement in research such as treatment outcomes or mechanisms. There has been an effort to implement DBT skills as a standalone treatment. More research is needed to assess how DBT skills work and for whom. As DBT broadens its reach, the treatment will continue to grow and adapt to meet demands of an evolving clinical landscape.

The prevalence and correlates of sexual risk behaviors and sexually transmitted infections in outpatients with borderline personality disorder.

This study examined the prevalence and correlates of sexual risk behaviors and sexually transmitted infections (STIs) in two samples of outpatients with borderline personality disorder (BPD), including suicidal BPD women (n = 99) and opiate-dependent BPD men and women (n = 125). High rates of sexual risk behaviors and STIs were found, particularly in the opiate-dependent BPD sample. Compared with suicidal BPD outpatients, opiate-dependent BPD outpatients reported higher rates of past-year sexual activity, commercial sex work, and lifetime hepatitis, as well as a greater number of lifetime sex partners. Substance use and demographic characteristics (age, sex, and marital status) were associated with higher rates of sexual risk behaviors and/or STIs, whereas cognitive-behavioral factors and indicators of psychiatric impairment were not. These findings point to a clear need for interventions aimed at decreasing sexual risk behaviors among individuals with BPD.

Treatment for Borderline Personality Disorder and Secondary Effects on Somatization.

Borderline personality disorder (BPD) is often accompanied by other diagnoses. Some comorbidities have received a good deal of attention, but others, including somatization, have not. As effective treatments for BPD are identified, the secondary effects of these treatments on BPD comorbidities are of clinical relevance. Secondary data were used from a randomized clinical trial of dialectical behavior therapy (DBT) and community treatment by experts among 101 women with BPD in order to characterize change in somatization with treatment for BPD, and to examine emotional avoidance as a mediator. Somatization decreased significantly over time, which did not differ by treatment condition. DBT had an indirect effect on somatization through less emotional avoidance. These results suggest that the comorbid presence of significant somatization should be evaluated among those with BPD, especially in the context of emotional avoidance; treatments could be enhanced by addressing emotion regulation skills.

Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators.

OBJECTIVE: This study evaluated mechanisms, mediation, and secondary/exploratory outcomes in our randomized controlled trial evaluating dialectical behavior therapy (DBT) compared to individual and group supportive therapy (IGST). We expand on previously reported results indicating a DBT advantage at posttreatment on planned suicide/self-harm outcomes, and greater self-harm remission (absence of self-harm, post hoc exploratory outcome) during active-treatment and follow-up periods. METHOD: This was a multi-site randomized trial of 173 adolescents with prior suicide attempts, self-harm, and suicidal ideation. Randomization was to 6 months of DBT or IGST, with outcomes monitored through 12 months. Youth emotion regulation was the primary mechanistic outcome. RESULTS: Compared to IGST, greater improvements in youth emotion regulation were found in DBT through the treatment-period [t(498) = 2.36, p = .019] and 12-month study period (t(498) = 2.93, p = .004). Their parents reported using more DBT skills: posttreatment t(497) = 4.12, p < .001); 12-month follow-up t(497) = 3.71, p < .001). Mediation analyses predicted to self-harm remission during the 6- to 12-month follow-up, the prespecified outcome and only suicidality/self-harm variable with a significant DBT effect at follow-up (DBT 49.3%; IGST 29.7%, p = .013). Improvements in youth emotion regulation during treatment mediated the association between DBT and self-harm remission during follow-up (months 6-12, estimate 1.71, CI 1.01-2.87, p = .045). Youths in DBT reported lower substance misuse, externalizing behavior, and total problems at posttreatment/6 months, and externalizing behavior throughout follow-up/12 months. CONCLUSION: Results support the significance of emotion regulation as a treatment target for reducing self-harm, and indicate a DBT advantage on substance misuse, externalizing behavior, and self-harm-remission, with 49.3% of youths in DBT achieving self-harm remission during follow-up. CLINICAL TRIAL REGISTRATION INFORMATION: Collaborative Adolescent Research on Emotions and Suicide; https://www.clinicaltrials.gov/; NCT01528020.

Dialectical behavior therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with borderline personality disorder.

This study examined the efficacy of dialectical behavior therapy (DBT) in reducing behaviors commonly used as exclusion criteria for posttraumatic stress disorder (PTSD) treatment. The sample included 51 suicidal and/or self-injuring women with borderline personality disorder (BPD), 26 (51%) of whom met criteria for PTSD. BPD clients with and without PTSD were equally likely to eliminate the exclusionary behaviors during 1 year of DBT. By posttreatment, 50-68% of the BPD clients with PTSD would have been suitable candidates for PTSD treatment. Borderline personality disorder clients with PTSD who began treatment with a greater number of recent suicide attempts and more severe PTSD were significantly less likely to become eligible for PTSD treatment.

The dialectical behavior therapy ways of coping checklist: development and psychometric properties.

Skills training is a crucial mode of treatment in dialectical behavioral therapy (DBT; Linehan, 1993b), yet a psychometrically sound measure of DBT skills use does not exist. We adapted the Revised Ways of Coping Checklist (RWCCL; Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) to create the DBT Ways of Coping Checklist (DBT-WCCL). Using factor analysis procedures, two subscales emerged: one assessing coping via DBT skills, the DBT Skills Subscale (DSS), and one assessing coping via dysfunctional means, the Dysfunctional Coping Subscale (DCS). Principal component, internal consistency, test-retest reliability, and content validity analyses suggested that the scale has good to excellent psychometric properties. In addition, the DSS successfully discriminated patients who received skills training during 4 months of treatment from patients who did not. Moderators of skills use are also discussed. The DBT-WCCL appears to be a promising new measure of DBT skills use.

Modeling the suicidal behavior cycle: Understanding repeated suicide attempts among individuals with borderline personality disorder and a history of attempting suicide.

OBJECTIVE: Suicide remains a leading cause of death in the United States, and recent reports have suggested the suicide rate is increasing. One of the most robust predictors of future suicidal behavior is a history of attempting suicide. Despite this, little is known about the factors that reduce the likelihood of reattempting suicide. This study compares theoretically derived suicide risk indicators to determine which factors are most predictive of future suicide attempts. METHOD: We used data from a randomized, controlled trial comparing 3 forms of dialectical behavior therapy (DBT; Linehan et al., 2015). Participants (N = 97, mean age = 30.3 years, 100% female, 71% White) met criteria for borderline personality disorder and had repeated and recent self-injurious behavior. Assessments occurred at 4-month intervals throughout 1 year of treatment and 1 year of follow-up. Time-lagged generalized linear mixed models (GLMMs) were used to evaluate relationship satisfaction, emotion dysregulation, and coping styles as predictors of suicide attempts. RESULTS: Both univariate and multivariate models suggested that higher between-person variance in problem-focused coping and lack of access to emotion regulation strategies were weakly associated with additional suicide attempts over the 2-year study. Within-person variance in the time-lagged predictors was not associated with subsequent suicide attempts. CONCLUSIONS: Among individuals with a recent suicide attempt, problem-focused coping and specific deficits in emotion regulation may differentiate those likely to reattempt from those who stop suicidal behavior during and after psychotherapy. These results suggest that treatments for recent suicide attempters should target increasing problem-focused coping and decreasing maladaptive emotion regulation skills. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Sleep in youth with repeated self-harm and high suicidality: Does sleep predict self-harm risk?

OBJECTIVE: To elucidate processes contributing to continuing self-harm in youth at very high risk for suicide, focusing on sleep disturbance, a putative warning sign of imminent suicide risk. METHOD: 101 youth (ages 12-18) selected for high risk of suicide/suicide attempts based on suicidal episodes plus repeated self-harm (suicide attempts and/or nonsuicidal self-injury [NSSI]). Youth were assessed at baseline, 6-, and 12-month follow-ups on measures of self-harm, suicidality, sleep, and depression. RESULTS: Youth showed high rates of baseline sleep disturbance: 81.2% scored in the clinical range on the Pittsburgh Sleep Quality Index (PSQI); 81.2% reported an evening (night owl) circadian preference. PSQI score was associated with elevated levels of self-harm (suicide attempts and NSSI) contemporaneously and predicted future self-harm within 30 days. Rates of self-harm were high during follow-up: 45.0% and 33.7% at 6 and 12 months, respectively. CONCLUSIONS: Results underscore the need to move beyond an acute treatment model to prevent recurrent and potentially deadly self-harm, the importance of clarifying mechanisms contributing to elevated suicide/self-harm risk, and the potential promise of engaging sleep as a therapeutic target for optimizing treatment and elucidating mechanistic processes.

A biosocial developmental model of borderline personality: Elaborating and extending Linehan's theory.

Over the past several decades, research has focused increasingly on developmental precursors to psychological disorders that were previously assumed to emerge only in adulthood. This change in focus follows from the recognition that complex transactions between biological vulnerabilities and psychosocial risk factors shape emotional and behavioral development beginning at conception. To date, however, empirical research on the development of borderline personality is extremely limited. Indeed, in the decade since M. M. Linehan initially proposed a biosocial model of the development of borderline personality disorder, there have been few attempts to test the model among at-risk youth. In this review, diverse literatures are reviewed that can inform understanding of the ontogenesis of borderline pathology, and testable hypotheses are proposed to guide future research with at-risk children and adolescents. One probable pathway is identified that leads to borderline personality disorder; it begins with early vulnerability, expressed initially as impulsivity and followed by heightened emotional sensitivity. These vulnerabilities are potentiated across development by environmental risk factors that give rise to more extreme emotional, behavioral, and cognitive dysregulation. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Assessing Suicidal and NonSuicidal Self-Injury via In-Depth Interview or Self-Report: Balancing Assessment Effort and Results.

OBJECTIVE: Both suicide and nonsuicidal self-injury (NSSI) represent major public health concerns, and effective assessment, management, and treatment requires assessment tools that can simultaneously be quick and accurate. This study compared the validity of a self-report measure of suicide attempts and NSSI acts with a gold standard in depth interview. METHOD: Ninety women answered questions about their suicidal behavior history using both a self-report assessment and in-depth interview. RESULTS: The plurality of patients over estimated their suicidal acts using the self-report measure when compared to the gold standard interview. CONCLUSION: Self-report assessments may not be an accurate method of retrieving information about suicide.

Emotional responses to self-injury imagery among adults with borderline personality disorder.

Nonsuicidal self-injury (NSSI) and suicide attempts (SAs) are especially prevalent in borderline personality disorder. One proposed mechanism for the maintenance of NSSI and SAs is escape conditioning, whereby immediate reductions in aversive emotional states negatively reinforce the behaviors. Psychophysiological and subjective indicators of negative emotion associated with NSSI and SA imagery were examined in 42 individuals who met criteria for border personality disorder. Personally relevant imagery scripts that involved an NSSI and/or an SA incident were created, as were control scenes involving imagery of an accidental injury, an accidental death, or an emotionally neutral event. Results did not support the hypothesis that decreases in negative emotion would occur during NSSI imagery; however, decreases were found during imagery of the moments after NSSI, which suggests some support for escape conditioning. Support for the model was not found for SAs. Possible implications of patterns that demonstrate decreases in negative emotion during accidental death imagery are discussed.

Distress and affective dysregulation in patients with borderline personality disorder: a psychophysiological ambulatory monitoring study.

Borderline personality disorder (BPD) is characterized by enduring psychological distress and affective dysregulation. Several models have linked both phenomena, but are lacking empirical support. To investigate the relation between psychological distress and components of affective dysregulation (especially inability to label emotions, conflictive emotions, and physiological hyperarousal), we repeatedly assessed these components using a 24-hour ambulatory monitoring approach in a group of 50 BPD patients and 50 healthy controls. Hierarchical linear model analyses identified a clear relation between inability to label emotions and distress in the BPD group (p = 0.0009) but not across all subjects (p = 0.6492). Conflictive emotions were related to psychological distress in both groups (p < 0.0001). This relation is, however, most pertinent to the BPD group who experienced conflicting emotions more frequently. Physiological arousal (heart rate) was related to distress in both groups. Our empirical findings emphasize training in labeling emotions and distress tolerance interventions in treatment for BPD.

On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder.

OBJECTIVE: Although previous research has suggested that people with a history of using psychiatric crisis services are at higher risk for suicide, it is unclear whether this link is attributable to individual risk factors or iatrogenic effects of service utilization. We examined this question by analyzing data from a randomized controlled trial of dialectical behavior therapy (DBT), a treatment for highly suicidal individuals in which patients took advantage of crisis services less than those in the comparison condition. We hypothesized that crisis-service utilization during a treatment year, rather than pretreatment indicators of suicide risk, would be associated with higher suicide risk after treatment, and that DBT's treatment effects would be partially attributable to this association. METHOD: Participants were 101 women (Mage = 29.3, 87% Caucasian) with recent suicidal and self-injurious behaviors meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) criteria for borderline personality disorder. We examined relationships between suicidal ideation (using the Suicide Behaviors Questionnaire; Linehan, 1981), number of suicide attempts (using the Suicide Attempt Self-Injury Interview; Linehan, Comtois, Brown, Heard, & Wagner, 2006), and number of psychiatric inpatient admissions and psychiatric emergency-room (ER) visits (using the Treatment History Interview; Linehan & Heard, 1987) from the years prior to, during, and following treatment. RESULTS: Treatment-year psychiatric ER visits were the sole predictor of the number of follow-up year suicide attempts. Treatment condition and pretreatment inpatient admissions predicted treatment-year psychiatric ER visits. Finally, there was evidence that DBT resulted in fewer suicide attempts at follow-up, in part because getting DBT led to fewer psychiatric ER visits. CONCLUSION: In this population and context, data suggest that crisis-service utilization conveys risk for suicide. DBT may reduce suicide risk in part by reducing use of these services. (PsycINFO Database Record

The Use of Virtual Reality to Facilitate Mindfulness Skills Training in Dialectical Behavioral Therapy for Spinal Cord Injury: A Case Study.

Introduction: Paralysis from a spinal cord injury (SCI) increases risk of psychological problems including suicide attempts, substance use disorder, negative emotions (e.g., anger), depression, anxiety, ASD/PTSD. Dialectical Behavioral Therapy® (DBT®) has been shown to be effective for treating similar psychological symptoms in non-SCI patient populations. The current study explored for the first time, the feasibility and clinical potential of using Immersive Virtual Reality (VR) enhanced DBT® Mindfulness skills training to help reduce psychological symptoms (negative emotions and anxiety, ASD/PTSD) of two patients with SCI. Patient 1 was a 39-year-old male patient suffering multiple spinal cord injuries, resulting in quadriplegia, after falling out of a four story building. Patient 1 had severe depression, and anxiety symptoms. Patient 2, was a 31 year old male with a C7 vertebral body fracture, leading to paresis, after suffering a blunt force trauma injury during an attempted suicide, jumping from a moving vehicle. Patient 2 had mild depression, and anxiety symptoms. Methods: Each patient looked into VR goggles, and had the illusion of slowly "floating down" a river in virtual reality while listening to DBT® Mindfulness Skills training instructions. Each patient filled out brief psychological ratings before and after each VR session, four VR DBT® sessions for patient 1, and two VR DBT® sessions for patient 2. Results: As predicted, patient 1 reported reductions in negative emotions after each VR DBT® Mindfulness session. Patient 2 had mixed results on some of the measures of negative emotions. And both patients reported feeling less depressed, less anxious, and less emotionally upset, after VR DBT® Mindfulness Skills learning. Patient 2 reported large reductions in short term ASD/PTSD symptoms after his first VR DBT® mindfulness skills training session. Conclusion: This study explored the feasibility of using VR DBT® with quadriplegic or paresis SCI patients. Both SCI patients accepted VR, the patients liked using VR, and, with assistance from the therapist, the patients were able to use the VR equipment, despite being paralyzed. Additional research and development will be needed to determine whether VR DBT® Mindfulness Skills training leads to any long term improvements in outcome.