Joaquim Soler

Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial

Dialectical behaviour therapy (DBT) has proven to be an effective treatment in borderline personality disorder (BPD). However, the effectiveness in BPD of DBT skills training (DBT-ST) alone is not known. This study aimed at comparing the efficacy of DBT-ST and standard group therapy (SGT) for outpatients with BPD. Sixty patients meeting the DSM-IV diagnostic criteria for BPD, as assessed by two semi-structured diagnostic interviews, were included in a 3-month, single-blind randomised controlled trial. A total of 13 weekly group psychotherapy sessions of 120 min of either SGT or DBT-ST were conducted. Assessments were carried out every 2 weeks by two blinded evaluators. Observer-rater, self-report scales and behavioural reports were used as outcome measures. DBT-ST was associated with lower dropout rates, 34.5% compared to 63.4% with SGT. It was superior to SGT in improving several mood and emotion areas, such as: depression, anxiety, irritability, anger and affect instability. A reduction in general psychiatric symptoms was also observed. Three-months weekly DBT-ST proved useful. This therapy was associated with greater clinical improvements and lower dropout rates than SGT. DBT-ST seems to play a role in the overall improvement of BPD seen with standard DBT intervention. It allows straightforward implementation in a wide range of mental health settings and provides the additional advantage that it is cost effective.

Psychometric properties of the Spanish validation of the Five Facets of Mindfulness Questionnaire (FFMQ)

Background and Objectives: Mindfulness-based therapies have demonstrat- ed effectiveness in many clinical contexts. Various therapies that train mindfulness skills have proliferated in recent years. There is increasing interest in mindfulness-based thera- pies and in incorporating instruments that measure mindfulness in order to understand its role in clinical and basic research. The Five Facets of Mindfulness Questionnaire (FFMQ) is a questionnaire for measuring mindfulness; it was derived from a factor analysis of five different questionnaires that measure a trait-like general tendency to be mindful in daily life. The objective of this study is to validate the FFMQ in a Spanish sample. Methods: The FFMQ was administered to a sample of 462 subjects ranging from 18 to 63 years (X = 27.9; SD = 9.75). The sample was composed by clinical (n = 146) and non- clinical (n = 226) subsamples. Results: The internal reliability of the scales ranged from acceptable to very good. Con- vergent analysis was conducted by computing Pearsons correlations, showing high corre- lations. The factorial structure is the same as that proposed by Baer et al. Conclusions: The FFMQ proved to be an effective instrument for measuring mindful- ness in clinical and non-clinical Spanish samples.

Neural correlates of impaired emotional discrimination in borderline personality disorder: An fMRI study

A common approach to study neuronal aspects of emotional reactivity of borderline personality disorder (BPD) is to study the brain response to emotional faces with functional magnetic resonance imaging (fMRI). 10 BPD patients and 10 matched controls were submitted to an emotional discrimination task in which subjects had to identify an emotional face from a neutral face while fMRI data was acquired. BPD patients made more mistakes than controls in the discrimination task when negative faces were involved. The emotional discrimination task activated brain areas that are known to participate in processing of emotional faces (fusiform gyrus, insula and amygdala) regardless of the psychiatric condition. Additionally, BPD showed higher activation than controls in the middle and inferior temporal cortical areas, brain areas that participate in the processing of face features that carry emotional value. Furthermore, activity at this site correlated with impulsivity score in the Zuckerman-Kuhlman Personality Questionnaire. Our findings may be related to cognitive impairment that may be characteristic of the disorder.

Effects of the dialectical behavioral therapy-mindfulness module on attention in patients with borderline personality disorder.

It is known that patients with borderline personality disorder (BPD) show attention deficits and impulsivity. The main aim of this study was to explore the effects of Dialectical Behavioral Therapy-Mindfulness training (DBT-M), used as an adjunct to general psychiatric management (GPM), on attention variables in patients diagnosed with BPD. A second objective was to assess the relation of mindfulness formal practice on clinical variables. A sample of 60 patients with BPD was recruited. Forty of them were allocated to GPM + DBT-M treatment and the other 20 received GPM alone. At the termination of the mindfulness training, DBT-M + GPM group showed a significant improvement on commissions, hit reaction time, detectability scores from the CPT-II neuropsychological test, and also on the composite scores of inattention and impulsivity. Further, the more minutes of mindfulness practice were correlated to greater improvement in general psychiatric symptoms and affective symptomatology, but not in CPT-II measures. This is probably the first study so far assessing the effects of this single DBT module in patients with BPD. The results suggest a positive effect of such intervention on attention and impulsivity variables.

Relationship between Meditative Practice and Self-Reported Mindfulness: The MINDSENS Composite Index

Mindfulness has been described as an inherent human capability that can be learned and trained, and its improvement has been associated with better health outcomes in both medicine and psychology. Although the role of practice is central to most mindfulness programs, practice-related improvements in mindfulness skills is not consistently reported and little is known about how the characteristics of meditative practice affect different components of mindfulness. The present study explores the role of practice parameters on self-reported mindfulness skills. A total of 670 voluntary participants with and without previous meditation experience (n = 384 and n = 286, respectively) responded to an internet-based survey on various aspects of their meditative practice (type of meditation, length of session, frequency, and lifetime practice). Participants also completed the Five Facets Mindfulness Questionnaire (FFMQ), and the Experiences Questionnaire (EQ). The group with meditation experience obtained significantly higher scores on all facets of FFMQ and EQ questionnaires compared to the group without experience. However different effect sizes were observed, with stronger effects for the Observing and Non-Reactivity facets of the FFMQ, moderate effects for Decentering in EQ, and a weak effect for Non-judging, Describing, and Acting with awareness on the FFMQ. Our results indicate that not all practice variables are equally relevant in terms of developing mindfulness skills. Frequency and lifetime practice – but not session length or meditation type – were associated with higher mindfulness skills. Given that these 6 mindfulness aspects show variable sensitivity to practice, we created a composite index (MINDSENS) consisting of those items from FFMQ and EQ that showed the strongest response to practice. The MINDSENS index was able to correctly discriminate daily meditators from non-meditators in 82.3% of cases. These findings may contribute to the understanding of the development of mindfulness skills and support trainers and researchers in improving mindfulness-oriented practices and programs.

Physiological Responses Induced by Emotion-Eliciting Films

Emotion-eliciting films are commonly used to evoke subjective emotional responses in experimental settings. The main aim of the present study was to investigate whether a set of film clips with discrete emotions were capable to elicit measurable objective physiological responses. The convergence between subjective and objective measures was evaluated. Finally, the effect of gender on emotional responses was investigated. A sample of 123 subjects participated in the study. Individuals were asked to view a set of emotional film clips capable to induce seven emotions: anger, fear, sadness, disgust, amusement, tenderness and neutral state. Skin conductance level (SCL), heart rate (HR) and subjective emotional responses were measured for each film clip. In comparison with neutral films, SCL was significantly increased after viewing fear films, and HR was also significantly incremented for anger and fear films. Physiological variations were associated with arousal measures indicating a convergence between subjective and objective reactions. Women appeared to display significantly greater SCL and HR responses for films inducing sadness. The findings suggest that physiological activation would be more easily induced by emotion-eliciting films that tap into emotions with higher subjective arousal such as anger and fear.

Association between methylation of the glucocorticoid receptor gene, childhood maltreatment, and clinical severity in borderline personality disorder.

The hypothalamus-pituitary-adrenal axis (HPA) is essential in the regulation of stress responses. Increased methylation of the promoter region of the glucocorticoid receptor gene (NR3C1) has been described both in subjects with history of childhood trauma and in patients with Borderline Personality Disorder (BPD). However, no data on the possible association between a higher methylation of this gene and clinical severity is available. The aim of this study was to evaluate the association between NR3C1 methylation status, the history of childhood trauma, and current clinical severity in subjects with BPD. A sample of 281 subjects with BPD (diagnosed by SCID-II and DIB-R semi-structured diagnostic interviews) was recruited. Clinical variables included previous hospitalizations, self-injurious behavior, and self-reported history of childhood trauma. DNA was extracted from peripheral blood. The results indicated a significant positive correlation between NR3C1 methylation status and childhood maltreatment (specifically physical abuse). In addition, a positive correlation between methylation status and clinical severity (DIB-R total score and hospitalizations) was observed. These findings suggest that NR3C1 methylation in subjects with BPD may be associated not only with childhood trauma but also with clinical severity, adding new evidence to the involvement of gene-environment interactions in this disorder.

Axis II comorbidity in borderline personality disorder is influenced by sex, age, and clinical severity.

Borderline personality disorder (BPD) is a severe psychiatric disorder that has a high clinical heterogeneity and frequent co-occurrence with other personality disorders (PDs). Although several studies have been performed to assess axis II comorbidity in BPD, more research is needed to clarify associated factors. The aim of this study was to determine the prevalence of co-occurrent axis II disorders in a large sample of patients with BPD and to investigate the influence of sex, age, and severity on this comorbidity. Data were collected from 484 patients with BPD through 2 semistructured interviews. We analyzed the frequency of axis II comorbidity and assessed differences regarding sex, age, and severity of BPD. About 74% of patients with BPD had at least 1 co-occurrent axis II disorder. The most common were paranoid, passive-aggressive, avoidant, and dependent PDs. Significant sex differences were found. Women presented more comorbidity with dependent PD, whereas men showed higher rates of comorbidity with antisocial PD. We also observed a significant positive correlation between age and the number of co-occurrent axis II disorders in women with BPD. Another finding was the positive correlation between BPD severity and the number of co-occurrent axis II disorders. These findings suggest that comorbidity with other axis II disorders and sex, age, and severity should be taken into account when developing treatment strategies and determining the prognosis of BPD.

Stages of change in dialectical behaviour therapy for borderline personality disorder.

OBJECTIVES The study aims at evaluating the suitability of applying the transtheoretical model (TTM) stage-of-change construct to the treatment with dialectical behaviour therapy (DBT) of borderline personality disorder (BPD). DESIGN Stages of change were assessed by means of the University of Rhode Island Change Assessment (URICA) scale prior to and after 3 months DBT skills group psychotherapy. METHOD The sample was comprised of 79 people with BPD (86% of females) at pre-treatment, and 42 patients (80% of females) at post-treatment. All patients were referred from clinical services and diagnosed by means of two semi-structured interviews. RESULTS In pre-treatment assessment, precontemplation scores correlated significantly and negatively with the other subscales (contemplation, action, and maintenance) and these three subscales also correlated significantly and positively with each other. The precontemplation stage was directly related to drop-out from the DBT group. The action subscale and the committed action (CA) composite score were significantly higher by the end of the DBT group treatment. However, with the absence of a control group it cannot be assured that these increases were directly related to DBT intervention. CONCLUSIONS In this observational design the stages of change of TTM seemed applicable to the DBT conceptualization of BPD and could further our understanding of the process of change in people with BPD treated with DBT.

Assessing decentering: validation, psychometric properties, and clinical usefulness of the Experiences Questionnaire in a Spanish sample.

Decentering is defined as the ability to observe ones thoughts and feelings in a detached manner. The Experiences Questionnaire (EQ) is a self-report instrument that originally assessed decentering and rumination. The purpose of this study was to evaluate the psychometric properties of the Spanish version of EQ-Decentering and to explore its clinical usefulness. The 11-item EQ-Decentering subscale was translated into Spanish and psychometric properties were examined in a sample of 921 adult individuals, 231 with psychiatric disorders and 690 without. The subsample of nonpsychiatric participants was also split according to their previous meditative experience (meditative participants, n=341; and nonmeditative participants, n=349). Additionally, differences among these three subgroups were explored to determine clinical validity of the scale. Finally, EQ-Decentering was administered twice in a group of borderline personality disorder, before and after a 10-week mindfulness intervention. Confirmatory factor analysis indicated acceptable model fit, sbχ(2)=243.8836 (p<.001), CFI=.939, GFI=.936, SRMR=.040, and RMSEA=.06 (.060-.077), and psychometric properties were found to be satisfactory (reliability: Cronbachs α=.893; convergent validity: r>.46; and divergent validity: r<-.35). The scale detected changes in decentering after a 10-session intervention in mindfulness (t=-4.692, p<.00001). Differences among groups were significant (F=134.8, p<.000001), where psychiatric participants showed the lowest scores compared to nonpsychiatric meditative and nonmeditative participants. The Spanish version of the EQ-Decentering is a valid and reliable instrument to assess decentering either in clinical and nonclinical samples. In addition, the findings show that EQ-Decentering seems an adequate outcome instrument to detect changes after mindfulness-based interventions.