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Abstract Background Borderline personality disorder (BPD) is considered a disorder of emotion regulation resulting from the expression of a biologically determined emotional vulnerability (that is, heightened sensitivity to emotion, increased emotional intensity/reactivity, and a slow return to emotional baseline) combined with exposure to invalidating environments. Vagal tone has been associated with activity in cortical regions involved in emotion regulation and a lower resting state of vagal tone has been observed in BPD patients relative to healthy controls. Non-invasive transcutaneous auricular vagus nerve stimulation (taVNS) has been shown to reduce temper outbursts in adults with Prader-Willi Syndrome, to enhance recognition of emotions in healthy students, and to improve depressive and anxiety symptoms. Furthermore, a single session of taVNS has been shown to acutely alter the recognition of facial expressions of negative valence in adolescents with MDD and increase emotion recognition in controls. However, the effect of taVNS on emotional vulnerability and regulation in individuals diagnosed with BPD has not been investigated. Our aims are to determine if taVNS is effective in acutely reducing emotional vulnerability and improve emotional regulation in BPD patients. Methods Forty-two patients will be randomized to a single session of taVNS or sham-taVNS while going through an affect induction procedure. It will consist of the presentation of one neutral and three negative affect-evoking 4-min-long videos in sequence, each of which is followed by a 4-min post-induction period during which participants will rate the quality and intensity of their current self-reported emotions (post-induction ratings) and the perceived effectiveness in managing their emotions during the video presentation. The rating of the current self-reported emotions will be repeated after every post-induction period (recovery ratings). Mixed models with individuals as random effect will be used to investigate the ratings at each stage of the study, taking into account the repeated measures of the same individuals at baseline, pre-induction, post-induction, and recovery. Discussion The study has potential to yield new insights into the role of vagal tone in emotion dysregulation in BPD and offer preliminary data on the effectiveness of taVNS as a possible non-invasive brain stimulation to treat a core symptom of BPD. Trial registration ClinicalTrials.gov NCT05892900. Retrospectively registered on Jun 07, 2023.

Abstract Background Dialectical Behaviour Therapy (DBT) is recognized as a leading evidence-based treatment, effective in reducing symptoms of borderline personality disorder (BPD), as well as co-occurring clinical syndromes. However, symptom remission may not be the same as a life experienced as worth living. The purpose of the study was to understand, from the perspective of individuals with lived experience, the concepts of recovery, life experienced as worth living and flourishing after treatment for BPD, and to describe the pathways to wellness after symptom remission. Methods Semi-structured interviews were conducted with nine adult women previously diagnosed with BPD, co-occurring clinical syndromes and severe self-harm behaviour who self-identified as recovered for a minimum of two years, recruited from a network for individuals with lived experience. The average duration of recovery was 5.7 years with a range from 2 to 10 + years. Data were analysed using thematic analysis. Results Four main themes and 14 subthemes were generated from our analyses. Main themes indicated that loved ones helped recovery and to create a life worth living, that participants identified as recovered and as healthy and beyond, and that becoming well is a long process associated in part with reclaiming a healthy identity. Participants defined recovery as separate but related to a life worth living, which in turn was separate but related to being healthy and having lives they described as being beyond health and well-being. The wellness process was described as lengthy and non-linear, including setbacks that with time no longer derailed daily life. A proposed theoretical model depicting the wellness process over time from symptom remission to the experience of a life beyond health and wellness is presented. Conclusions This qualitative study contributes knowledge of what a life experienced as worth living means, as well as how wellness progressed into flourishing for some participants within a sample of individuals with lived experience. Our findings may inform treatment development that targets more than symptom reduction, which in turn may shorten trajectories from symptom remission to health, wellness, and flourishing.

IntroductionThe Five Self-Harm Behavior Groupings Measure (5S-HM) is a novel assessment that evaluates behaviours which may go undetected by existing measures. Self-harm is formulated across directness and lethality spectra, including under-studied behaviors such as indirect self-harm, harmful self-neglect and sexual self-harm. Aims of the study were to: (1) empirically evaluate the 5S-HM; (2) to determine whether the 5S-HM generates relevant new information with respect to the forms and functions given by participants for self-harm within a clinical sample; (3) to test the utility and novel contributions of the Unified Model of Self-Harm and the 5S-HM by extension.MethodsData were collected from N = 199 individuals (Mage = 29.98, SD = 8.41, 86.4% female), receiving specialized evidence-based treatments for self-harm, borderline personality disorder or eating disorders. Construct validity was determined via Spearman correlations, and internal consistency was established from Cronbach’s alpha. Inductive thematic analysis was used to analyze and interpret qualitative data on reasons, forms and functions participants reported in relation to self-harm following Braun and Clarke’s analytic guidelines. Thematic mapping was used to summarize qualitative data.ResultsTest-retest reliability on a subsample of n = 24, tested 14 days after Time 1 was supported by a good intraclass correlation (0.68). Internal consistency (Cronbach’s alpha = 0.75) was acceptable to good, as was construct validity comparing the 5S-HM total score to two validated self-harm measures (rho = 0.40, p < 0.01; rho = 0.26, p < 0.01). A thematic map depicting antecedents and consequences of self-harm over time suggests that self-harm is initiated by negative emotional states and self-intolerance. Novel findings in relation to sexual self-harm indicated that reasons for these behaviors were either to improve or worsen one’s situation through being hurt by someone else.DiscussionThe empirical analyses of the 5S-HM demonstrate that it is a robust measure for use in clinical and research settings. Thematic analyses proposed explanations for why self-harm behaviors are initiated and how they are reinforced over time. Sexual self-harm in particular requires further careful study.

Background: Transcutaneous vagus nerve stimulation (tVNS) has been suggested as a treatment method for depression. Methods: A systematic review to systematically evaluate the efficacy of tVNS for the treatment of depression was conducted according to PRISMA guidelines. Primary outcomes were mortality, self-harm, depressive symptoms, and health-related quality of life (HRQoL). Secondary outcomes were anxiety symptoms, medication use, everyday functioning, complications, and patients’ experiences of treatment. Five databases were searched systematically. The included articles were critically appraised and certainty of evidence was assessed using GRADE. Results: Two studies evaluating efficacy and a case series collecting data on complications were included. One randomized trial (n = 37) and one cohort study (n = 160) comparing tVNS with sham-tVNS reported significant reduction in the tVNS group of self-rated (SMD = -0.82, 95%-CI = -1.50, -0.15) but not clinician-rated depressive symptoms, after two weeks, and of both self-rated (SMD = -0.99, 95%-CI = -1.32, -0.66) and clinician-rated (SMD = -0.89, 95%-CI = -1.22, -0.57) depressive symptoms, after four weeks, respectively. Furthermore, the cohort study found reduction of both self-rated (SMD = -0.66, 95%-CI = -0.98, -0.34) and clinician-rated (SMD = -0.14, 95%-CI = -0.46, 0.17) anxiety symptoms. One case series (n = 12), collecting data on complications, reported mild to moderate transient side effects. Limitations: Available studies are few and heterogeneous, have major study limitations, problems with directness and imprecision. Conclusions: It is uncertain whether tVNS reduces depressive symptoms and anxiety. Although existing studies show promising results, further studies are needed to increase the certainty of evidence.

Abstract Background Family Connections (FC) is a multi-family skills training program for relatives of individuals with borderline personality disorder (BPD) and related difficulties, typically offered once per week for 12–14 weeks. Families with loved ones receiving residential Dialectical Behaviour Therapy DBT (DBT-R) in a different community, or those with multiple caregiving demands may have difficulty participating in weekly standard FC (FC-S). The aims of this paper are to: 1) Evaluate the results of the FC-S approach compared with an intensified weekend FC model developed for family members whose relatives are in DBT-R (FC-R); 2) Evaluate outcomes of FC-R for families with loved ones returning home from DBT-R, as little is known about how this population fares. Methods Data were collected at pre-treatment (T1), post-treatment (T2), and at six-to-seven-month follow-up (T3) in this non-randomized comparison study. A total of 82 family members participated, 34 of whom completed the FC-S program and 48 of whom completed the FC-R program. The evaluation was based upon outcomes derived from a standard battery used in FC research, analyzed by time and treatment setting. A composite score to evaluate family distress was generated. Two-way mixed multivariate analyses of variance (MANOVA) were employed to evaluate time (pre-versus-post versus follow-up) and group (FC-S versus FC-R). Results Scores on measures of mental health difficulties (General Severity Index), sense of burden (Burden Assessment Scale), and Global Family Functioning showed improvement over time. Having a loved one return home from DBT-R was associated with worsening on the GSI and the BAS at post-test. Notably, this deterioration was not found at follow-up. Conclusions Little is known about families with loved ones receiving DBT-R other than the fact that their loved ones had not responded to previous services, which suggests greater complexity and chronicity. Because the family members receiving the weekend intensive FC-R version of FC demonstrated improvement, preliminary support exists for service providers to use the weekend intensive FC-R model as a time-and-cost efficient option whenever barriers exist to participating in weekly FC-S. Our findings also suggest that booster sessions may be indicated for families receiving loved ones home from DBT-R programs.

Non-suicidal self-injury (NSSI), the direct, deliberate destruction of one’s own bodily tissue in the absence of an intent to die, is frequently used for evaluating treatment in clinical care. One instrument for assessing NSSI is the Inventory of Statements About Self-Injury (ISAS). The ISAS is a self-rating measure examining the lifetime frequencies of NSSI behaviors and further exploring NSSI functions. The study aimed to examine the consistency of self-reported lifetime NSSI frequencies and functions (via the ISAS) in a clinical sample of individuals with current self-harm and/or recurrent suicidal behaviors over one year. Fifty-two individuals (84.6% women) completed the ISAS three times over 1 year. We found relatively good test-retest stability for most NSSI behaviors and functions, but the correlation coefficients and frequencies of NSSI behaviors varied substantially. Approximately, 50% of participants reported lower lifetime frequencies of NSSI behaviors at the later time points, with approximately 20% reporting a significant reduction in their lifetime frequencies over one year. This unexpected finding raises concerns about the accuracy of reporting lifetime NSSI frequencies among individuals with multiple psychiatric diagnoses and extensive NSSI behaviors across their lives. Further research is needed to determine more reliable ways of collecting data on the lifetime frequency of NSSI in clinical samples and the accuracy of lifetime NSSI frequency estimates in general.

Abstract Background To investigate the outcome of an integrated individual and family therapy (Intensive Contextual Treatment: ICT) in terms of reducing suffering and increasing functional adjustment among self-harming and/or suicidal adolescents with high symptom loads and their families. Methods Forty-nine self-harming and/or suicidal adolescents, Mage = 14.6, of predominantly Swedish origin and female gender (85.7%) participated with their parents. The study had a within group design with repeated measures at pre- and post-treatment, as well as six- and twelve-months follow-ups. Self-reports were used for the main outcomes; self-harm rates, suicide attempts, parent-reported days of inpatient/institutional care, internalized and externalized symptoms, perceived stress, emotion regulation, school hours and adjustment. Secondary outcomes were levels of reported expressed emotions within family dyads, as well as parental anxiety, depression and stress. Results From pre- to post-assessment, the adolescents reported significant reductions of self-harm (p = .001, d = 0.54) and suicide attempts (p

Abstract Background Brief Admission is a crisis and risk management strategy in which self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder self-admit to hospital at times of increasing risk when other efforts to stay safe are failing. Standardized in the current randomized controlled trial, the intensity of Brief Admission Skåne is implemented in durations of three days, with a maximum frequency of three times a month. Brief Admission is integrated into existing treatment plans in advance of crises to prevent reliance on general psychiatric admissions for risk management, as these may be lengthy, unstructured, and of uncertain therapeutic value. Methods/design The overall objective of the Brief Admission Skåne randomized controlled trial is to determine if Brief Admission can replace general psychiatric admission for self-harming and suicidal individuals with complex mental illness at times of escalating risk. Other objectives of the study are to evaluate whether Brief Admission increases daily functioning and enhances coping, reduces psychiatric symptoms including frequency and severity of self-harm and suicidal behaviours. A final objective is to determine if Brief Admission is an effective crisis management model for this population. Participants are randomized at an individual level to either Brief Admission Skåne plus Treatment as Usual or Treatment As Usual. Based on a priori power analyses, N = 124 participants will be recruited to the study. Data collection is in progress, and will continue until June 2018. All participant data are single-blinded and will be handled with intention-to-treat analysis. Discussion Based on the combined clinical experience of our international research group, the Brief Admission Skåne randomized controlled trial upon which the current protocol is based represents the first initiative to standardize, implement and evaluate Brief Admission amongst self-harming and suicidal individuals, including those with borderline traits. Objectively measuring protocol fidelity and developing English-language Brief Admission study protocols and training materials are implementation and dissemination targets developed in order to facilitate adherent international export of Brief Admission Skåne. Trial registration NCT02985047 . Registered November 25, 2016. Retrospectively registered.